NUR 256 Exam 4 V2 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most appropriate nursing intervention?
A. Ask the client what the voices are saying to assess for safety.
B. Tell the client that there are no voices and it is just their imagination.
C. Leave the client alone to allow them to process the experience.
D. Agree with the client that the voices are real to build rapport.
Answer: A
Rationale: The nurse must first assess if the hallucinations are command in nature to
ensure the safety of the client and others. Acknowledging the client’s feelings without
reinforcing the hallucination is a therapeutic approach. Ignoring the hallucination or
arguing about its reality is non-therapeutic and can increase client anxiety.
2. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value should the nurse monitor most closely?
A. Serum creatinine
B. Serum potassium
,C. White blood cell (WBC) count
D. Hemoglobin and Hematocrit
Answer: C
Rationale: Clozapine carries a high risk for agranulocytosis, which is a life-threatening
decrease in white blood cells. Clients must have baseline and weekly blood draws to
monitor for this condition. If the WBC count falls below a specific threshold, the medication
must be discontinued immediately.
3. A client with bipolar disorder is in a manic phase. What is the priority nursing intervention?
A. Encouraging the client to participate in group therapy.
B. Discussing the client’s childhood traumas in detail.
C. Allowing the client to lead the community meeting.
D. Providing the client with high-calorie finger foods.
Answer: D
Rationale: During mania, clients are often too hyperactive to sit down for full meals,
putting them at risk for exhaustion and malnutrition. High-calorie finger foods allow the
client to maintain nutrition while on the move. Safety and physiological stability are the
highest priorities during an acute manic episode.
, 4. Which of the following describes the therapeutic serum lithium level for a client in the
maintenance phase?
A. 0.1 - 0.5 mEq/L
B. 0.6 - 1.2 mEq/L
C. 1.5 - 2.0 mEq/L
D. 2.5 - 3.5 mEq/L
Answer: B
Rationale: The therapeutic window for lithium is very narrow, typically ranging from 0.6
to 1.2 mEq/L for maintenance therapy. Levels above 1.5 mEq/L are considered toxic and
require immediate medical intervention. Regular blood monitoring is essential to prevent
toxicity and ensure efficacy.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which symptom
should the nurse report immediately?
A. Dry mouth and blurred vision
B. Muscular rigidity and high fever
C. Increased appetite and weight gain
D. Nasal congestion and cough
Answer: B
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 4) | Galen
College of Nursing
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most appropriate nursing intervention?
A. Ask the client what the voices are saying to assess for safety.
B. Tell the client that there are no voices and it is just their imagination.
C. Leave the client alone to allow them to process the experience.
D. Agree with the client that the voices are real to build rapport.
Answer: A
Rationale: The nurse must first assess if the hallucinations are command in nature to
ensure the safety of the client and others. Acknowledging the client’s feelings without
reinforcing the hallucination is a therapeutic approach. Ignoring the hallucination or
arguing about its reality is non-therapeutic and can increase client anxiety.
2. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
value should the nurse monitor most closely?
A. Serum creatinine
B. Serum potassium
,C. White blood cell (WBC) count
D. Hemoglobin and Hematocrit
Answer: C
Rationale: Clozapine carries a high risk for agranulocytosis, which is a life-threatening
decrease in white blood cells. Clients must have baseline and weekly blood draws to
monitor for this condition. If the WBC count falls below a specific threshold, the medication
must be discontinued immediately.
3. A client with bipolar disorder is in a manic phase. What is the priority nursing intervention?
A. Encouraging the client to participate in group therapy.
B. Discussing the client’s childhood traumas in detail.
C. Allowing the client to lead the community meeting.
D. Providing the client with high-calorie finger foods.
Answer: D
Rationale: During mania, clients are often too hyperactive to sit down for full meals,
putting them at risk for exhaustion and malnutrition. High-calorie finger foods allow the
client to maintain nutrition while on the move. Safety and physiological stability are the
highest priorities during an acute manic episode.
, 4. Which of the following describes the therapeutic serum lithium level for a client in the
maintenance phase?
A. 0.1 - 0.5 mEq/L
B. 0.6 - 1.2 mEq/L
C. 1.5 - 2.0 mEq/L
D. 2.5 - 3.5 mEq/L
Answer: B
Rationale: The therapeutic window for lithium is very narrow, typically ranging from 0.6
to 1.2 mEq/L for maintenance therapy. Levels above 1.5 mEq/L are considered toxic and
require immediate medical intervention. Regular blood monitoring is essential to prevent
toxicity and ensure efficacy.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which symptom
should the nurse report immediately?
A. Dry mouth and blurred vision
B. Muscular rigidity and high fever
C. Increased appetite and weight gain
D. Nasal congestion and cough
Answer: B
