NSG 3450 Final Exam V1 | NSG 3450
Mental Health Guide | Actual Q&A with
Rationale (NSG3450 Final Exam) | Galen
College of Nursing
1. A nurse is caring for a client who has a prescription for lithium carbonate. Which of the
following findings should the nurse identify as an early sign of lithium toxicity?
A. Coarse tremors
B. Nausea and vomiting
C. Tinnitus
D. Mental confusion
Answer: B
Rationale: Early signs of lithium toxicity include gastrointestinal upset such as nausea,
vomiting, and diarrhea. As levels rise, the client may progress to more severe neurological
symptoms like coarse tremors or ataxia. The nurse should monitor serum lithium levels
closely to ensure they remain within the therapeutic range of 0.6 to 1.2 mEq/L.
2. A client diagnosed with schizophrenia states, ‘The government has planted a chip in my
brain to track my thoughts.’ The nurse should identify this statement as which of the
following?
A. Hallucination
,B. Ideas of reference
C. Persecutory delusion
D. Grandiosity
Answer: C
Rationale: Persecutory delusions involve the belief that one is being singled out for harm
or followed by others. The nurse must refrain from arguing with the client about the reality
of the delusion. Instead, focusing on the feelings associated with the delusion helps build a
therapeutic rapport.
3. Which of the following interventions is the priority for a nurse when caring for a client
experiencing a panic level of anxiety?
A. Teach the client relaxation techniques.
B. Ask the client to describe their feelings.
C. Provide a low-stimulus environment.
D. Explain the physiological causes of anxiety.
Answer: C
Rationale: During a panic attack, the client’s ability to process information is severely
limited. Providing a calm, low-stimulus environment helps reduce the overwhelming
sensory input. The nurse should stay with the client and use short, simple sentences until
the panic subsides.
, 4. A nurse is monitoring a client who is taking clozapine. Which of the following laboratory
results should the nurse report to the provider immediately?
A. Platelet count of 150,000/mm3
B. WBC count of 2,500/mm3
C. Hemoglobin of 14 g/dL
D. Blood glucose of 110 mg/dL
Answer: B
Rationale: Clozapine is associated with a high risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. A WBC count below 3,000/mm3 requires
immediate notification of the provider and discontinuation of the medication. Regular
hematological monitoring is a mandatory requirement for clients on this antipsychotic
therapy.
5. A nurse is performing a suicide risk assessment for a newly admitted client. Which of the
following factors should the nurse identify as the highest risk for completed suicide?
A. The client has a history of depression.
B. The client has a specific plan and access to a firearm.
C. The client lives alone in a rural area.
D. The client is experiencing job-related stress.
Answer: B
Mental Health Guide | Actual Q&A with
Rationale (NSG3450 Final Exam) | Galen
College of Nursing
1. A nurse is caring for a client who has a prescription for lithium carbonate. Which of the
following findings should the nurse identify as an early sign of lithium toxicity?
A. Coarse tremors
B. Nausea and vomiting
C. Tinnitus
D. Mental confusion
Answer: B
Rationale: Early signs of lithium toxicity include gastrointestinal upset such as nausea,
vomiting, and diarrhea. As levels rise, the client may progress to more severe neurological
symptoms like coarse tremors or ataxia. The nurse should monitor serum lithium levels
closely to ensure they remain within the therapeutic range of 0.6 to 1.2 mEq/L.
2. A client diagnosed with schizophrenia states, ‘The government has planted a chip in my
brain to track my thoughts.’ The nurse should identify this statement as which of the
following?
A. Hallucination
,B. Ideas of reference
C. Persecutory delusion
D. Grandiosity
Answer: C
Rationale: Persecutory delusions involve the belief that one is being singled out for harm
or followed by others. The nurse must refrain from arguing with the client about the reality
of the delusion. Instead, focusing on the feelings associated with the delusion helps build a
therapeutic rapport.
3. Which of the following interventions is the priority for a nurse when caring for a client
experiencing a panic level of anxiety?
A. Teach the client relaxation techniques.
B. Ask the client to describe their feelings.
C. Provide a low-stimulus environment.
D. Explain the physiological causes of anxiety.
Answer: C
Rationale: During a panic attack, the client’s ability to process information is severely
limited. Providing a calm, low-stimulus environment helps reduce the overwhelming
sensory input. The nurse should stay with the client and use short, simple sentences until
the panic subsides.
, 4. A nurse is monitoring a client who is taking clozapine. Which of the following laboratory
results should the nurse report to the provider immediately?
A. Platelet count of 150,000/mm3
B. WBC count of 2,500/mm3
C. Hemoglobin of 14 g/dL
D. Blood glucose of 110 mg/dL
Answer: B
Rationale: Clozapine is associated with a high risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. A WBC count below 3,000/mm3 requires
immediate notification of the provider and discontinuation of the medication. Regular
hematological monitoring is a mandatory requirement for clients on this antipsychotic
therapy.
5. A nurse is performing a suicide risk assessment for a newly admitted client. Which of the
following factors should the nurse identify as the highest risk for completed suicide?
A. The client has a history of depression.
B. The client has a specific plan and access to a firearm.
C. The client lives alone in a rural area.
D. The client is experiencing job-related stress.
Answer: B
