NUR 256 Exam 2 V3 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 2) | Galen
College of Nursing
1. A nurse is assessing a client with moderate anxiety. Which of the following findings should
the nurse expect?
A. Dilated pupils and cool skin
B. Narrowed perceptual field
C. Inability to focus on a single task
D. Heightened sensory awareness
Answer: B
Rationale: Moderate anxiety causes a narrowed perceptual field where the client sees,
hears, and grasps less information than before. The client remains able to solve problems
but may require assistance to stay focused on the task at hand. This level of anxiety is
distinct from mild anxiety, which typically involves heightened sensory awareness and
improved problem-solving.
2. A client is experiencing a panic attack in the dayroom. Which action should the nurse take
first?
A. Instruct the client to use deep breathing exercises
,B. Administer PRN lorazepam immediately
C. Take the client to a quiet, secluded area
D. Ask the client to describe what triggered the attack
Answer: C
Rationale: The priority intervention for a client in panic-level anxiety is to ensure safety
and reduce environmental stimuli. Moving the client to a quiet, less crowded area helps
decrease sensory overload and provides a sense of security. Once the client is in a safer
environment, the nurse can then utilize further calming techniques such as deep breathing.
3. A client newly diagnosed with Obsessive-Compulsive Disorder (OCD) spends 45 minutes
washing their hands before meals. What is the most appropriate initial nursing intervention?
A. Allow the client enough time to perform the ritual
B. Set strict time limits on the handwashing ritual
C. Place a sign over the sink stating ‘No Handwashing’
D. Ask the client why they feel the need to wash so often
Answer: A
Rationale: Initially, the nurse should allow the client to perform the ritual to prevent an
overwhelming increase in anxiety. Forcing a client to stop a ritual abruptly without
teaching coping mechanisms can lead to panic or extreme distress. The goal is to gradually
, limit the time spent on rituals as the client develops healthier coping strategies through
therapy.
4. A nurse is caring for a client with Post-Traumatic Stress Disorder (PTSD). Which clinical
manifestation is a hallmark sign of this disorder?
A. Splitting and manipulation
B. Hypervigilance and exaggerated startle response
C. Ritualistic behaviors to reduce anxiety
D. Flight of ideas and pressured speech
Answer: B
Rationale: Hypervigilance and an exaggerated startle response are classic symptoms of the
physiological arousal found in PTSD. These symptoms result from the client being in a
constant state of ‘fight or flight’ due to the trauma experienced. Other common symptoms
include intrusive memories, flashbacks, and avoidance of triggers related to the event.
5. A client is admitted for Major Depressive Disorder (MDD). What is the highest priority
assessment for this client?
A. Daily intake of nutrition and fluids
B. Level of interest in unit activities
C. Sleep patterns and hygiene habits
D. Risk for self-harm or suicidal ideation
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 2) | Galen
College of Nursing
1. A nurse is assessing a client with moderate anxiety. Which of the following findings should
the nurse expect?
A. Dilated pupils and cool skin
B. Narrowed perceptual field
C. Inability to focus on a single task
D. Heightened sensory awareness
Answer: B
Rationale: Moderate anxiety causes a narrowed perceptual field where the client sees,
hears, and grasps less information than before. The client remains able to solve problems
but may require assistance to stay focused on the task at hand. This level of anxiety is
distinct from mild anxiety, which typically involves heightened sensory awareness and
improved problem-solving.
2. A client is experiencing a panic attack in the dayroom. Which action should the nurse take
first?
A. Instruct the client to use deep breathing exercises
,B. Administer PRN lorazepam immediately
C. Take the client to a quiet, secluded area
D. Ask the client to describe what triggered the attack
Answer: C
Rationale: The priority intervention for a client in panic-level anxiety is to ensure safety
and reduce environmental stimuli. Moving the client to a quiet, less crowded area helps
decrease sensory overload and provides a sense of security. Once the client is in a safer
environment, the nurse can then utilize further calming techniques such as deep breathing.
3. A client newly diagnosed with Obsessive-Compulsive Disorder (OCD) spends 45 minutes
washing their hands before meals. What is the most appropriate initial nursing intervention?
A. Allow the client enough time to perform the ritual
B. Set strict time limits on the handwashing ritual
C. Place a sign over the sink stating ‘No Handwashing’
D. Ask the client why they feel the need to wash so often
Answer: A
Rationale: Initially, the nurse should allow the client to perform the ritual to prevent an
overwhelming increase in anxiety. Forcing a client to stop a ritual abruptly without
teaching coping mechanisms can lead to panic or extreme distress. The goal is to gradually
, limit the time spent on rituals as the client develops healthier coping strategies through
therapy.
4. A nurse is caring for a client with Post-Traumatic Stress Disorder (PTSD). Which clinical
manifestation is a hallmark sign of this disorder?
A. Splitting and manipulation
B. Hypervigilance and exaggerated startle response
C. Ritualistic behaviors to reduce anxiety
D. Flight of ideas and pressured speech
Answer: B
Rationale: Hypervigilance and an exaggerated startle response are classic symptoms of the
physiological arousal found in PTSD. These symptoms result from the client being in a
constant state of ‘fight or flight’ due to the trauma experienced. Other common symptoms
include intrusive memories, flashbacks, and avoidance of triggers related to the event.
5. A client is admitted for Major Depressive Disorder (MDD). What is the highest priority
assessment for this client?
A. Daily intake of nutrition and fluids
B. Level of interest in unit activities
C. Sleep patterns and hygiene habits
D. Risk for self-harm or suicidal ideation
