NUR 256 Exam 1 V1 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 1) | Galen
College of Nursing
1. A nurse is providing care for a client who has been voluntarily admitted to the psychiatric
unit. The client requests to leave the hospital against medical advice (AMA). Which action
should the nurse take first?
A. Allow the client to sign the necessary documents and leave immediately.
B. Initiate an involuntary commitment process to ensure the client stays.
C. Administer a sedative to prevent the client from leaving the facility.
D. Notify the healthcare provider and assess the client for potential harm to self or others.
Answer: D
Rationale: Voluntarily admitted clients have the right to request discharge, but the nurse
must first assess for safety. If the client is deemed a danger to themselves or others, the
status may be changed to involuntary. This assessment is the priority step in the legal and
ethical management of the situation.
2. According to Maslow’s Hierarchy of Needs, which assessment finding would the nurse
prioritize for a psychiatric client?
A. The client expresses a lack of purpose and low self-esteem.
,B. The client reports feeling unsafe in their current living environment.
C. The client has not consumed food or fluids for the past 48 hours.
D. The client feels isolated and lacks a supportive social network.
Answer: C
Rationale: Maslow’s hierarchy dictates that physiological needs must be met before
higher-level psychological needs. Lack of nutrition and hydration poses an immediate
threat to physical health and stability. The nurse must address these basic life-sustaining
needs as the highest priority during the assessment phase.
3. A nurse is using therapeutic communication with a client who states, ‘I feel like my family
would be better off without me.’ Which response by the nurse is most appropriate?
A. ‘Why would you say something so hurtful about yourself?’
B. ‘Don’t worry, your family loves you very much and needs you.’
C. ‘You are feeling like your family no longer needs your support?’
D. ‘I think you should focus on the positive aspects of your life instead.’
Answer: C
Rationale: The nurse is using the technique of restating or reflection to encourage the
client to elaborate. This approach validates the client’s feelings without passing judgment
or providing false reassurance. It allows the nurse to further assess the client’s suicidal
ideation or feelings of worthlessness.
, 4. A client is prescribed a Selective Serotonin Reuptake Inhibitor (SSRI). The nurse should
educate the client about which potential side effect?
A. Sexual dysfunction and gastrointestinal upset.
B. Tardive dyskinesia and muscle rigidity.
C. Acute hypertensive crisis following tyramine consumption.
D. Weight loss and increased appetite.
Answer: A
Rationale: Sexual dysfunction and GI issues are common side effects associated with SSRI
medications. These symptoms often lead to non-compliance if the patient is not properly
educated beforehand. The nurse should explain that some side effects may diminish over
time while others may require a medication adjustment.
5. A nurse is caring for a client who is experiencing a manic episode. Which environmental
intervention is most appropriate?
A. Provide a highly stimulating environment with multiple activities.
B. Allow the client to pace in the hallway to burn off excess energy.
C. Encourage the client to participate in group therapy sessions immediately.
D. Place the client in a quiet room with dimmed lighting and minimal stimuli.
Answer: D
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 1) | Galen
College of Nursing
1. A nurse is providing care for a client who has been voluntarily admitted to the psychiatric
unit. The client requests to leave the hospital against medical advice (AMA). Which action
should the nurse take first?
A. Allow the client to sign the necessary documents and leave immediately.
B. Initiate an involuntary commitment process to ensure the client stays.
C. Administer a sedative to prevent the client from leaving the facility.
D. Notify the healthcare provider and assess the client for potential harm to self or others.
Answer: D
Rationale: Voluntarily admitted clients have the right to request discharge, but the nurse
must first assess for safety. If the client is deemed a danger to themselves or others, the
status may be changed to involuntary. This assessment is the priority step in the legal and
ethical management of the situation.
2. According to Maslow’s Hierarchy of Needs, which assessment finding would the nurse
prioritize for a psychiatric client?
A. The client expresses a lack of purpose and low self-esteem.
,B. The client reports feeling unsafe in their current living environment.
C. The client has not consumed food or fluids for the past 48 hours.
D. The client feels isolated and lacks a supportive social network.
Answer: C
Rationale: Maslow’s hierarchy dictates that physiological needs must be met before
higher-level psychological needs. Lack of nutrition and hydration poses an immediate
threat to physical health and stability. The nurse must address these basic life-sustaining
needs as the highest priority during the assessment phase.
3. A nurse is using therapeutic communication with a client who states, ‘I feel like my family
would be better off without me.’ Which response by the nurse is most appropriate?
A. ‘Why would you say something so hurtful about yourself?’
B. ‘Don’t worry, your family loves you very much and needs you.’
C. ‘You are feeling like your family no longer needs your support?’
D. ‘I think you should focus on the positive aspects of your life instead.’
Answer: C
Rationale: The nurse is using the technique of restating or reflection to encourage the
client to elaborate. This approach validates the client’s feelings without passing judgment
or providing false reassurance. It allows the nurse to further assess the client’s suicidal
ideation or feelings of worthlessness.
, 4. A client is prescribed a Selective Serotonin Reuptake Inhibitor (SSRI). The nurse should
educate the client about which potential side effect?
A. Sexual dysfunction and gastrointestinal upset.
B. Tardive dyskinesia and muscle rigidity.
C. Acute hypertensive crisis following tyramine consumption.
D. Weight loss and increased appetite.
Answer: A
Rationale: Sexual dysfunction and GI issues are common side effects associated with SSRI
medications. These symptoms often lead to non-compliance if the patient is not properly
educated beforehand. The nurse should explain that some side effects may diminish over
time while others may require a medication adjustment.
5. A nurse is caring for a client who is experiencing a manic episode. Which environmental
intervention is most appropriate?
A. Provide a highly stimulating environment with multiple activities.
B. Allow the client to pace in the hallway to burn off excess energy.
C. Encourage the client to participate in group therapy sessions immediately.
D. Place the client in a quiet room with dimmed lighting and minimal stimuli.
Answer: D
