,NUR 253 Exam 3 – Concepts of Mental Health
Nursing – Actual Q&A (GCN) (Updated PDF)
1. A client with post-traumatic stress disorder following a motor vehicle
accident is most likely to exhibit which finding?
A) Recurrent, intrusive distressing memories of the accident
B) Gratitude for surviving and optimism about the future
C) Repeatedly seeking out the accident scene
D) Complete loss of all memory of the accident
Correct Answer: A) Recurrent, intrusive distressing memories of the accident
Rationale: Intrusive symptoms, including recurrent involuntary memories,
flashbacks, and nightmares, are core features of PTSD. Avoidance, not seeking
out the trauma, is typical. Complete memory loss suggests dissociative amnesia.
2. A client with major depressive disorder states, “I don’t see the point in going
on.” What is the priority nursing action?
A) Encourage group therapy attendance
B) Assess for suicide risk, including plan and means
C) Teach about antidepressant side effects
D) Ensure adequate nutritional intake
Correct Answer: B) Assess for suicide risk, including plan and means
,Rationale: Safety is the priority in mental health nursing. A statement of
hopelessness indicates increased suicide risk. The nurse must directly assess
suicidal ideation, plan, and means, and initiate precautions if needed.
3. A client prescribed fluoxetine reports nausea, headache, and insomnia. Which
response is most appropriate?
A) Stop the medication immediately
B) Go to the emergency department
C) These are common side effects that often resolve in a few weeks
D) Switch to a different medication immediately
Correct Answer: C) These are common side effects that often resolve in a few
weeks
Rationale: Nausea, headache, and insomnia are common early side effects of
SSRIs and typically resolve within a few weeks. Clients should be encouraged to
continue the medication and not stop abruptly.
4. A client is found wandering and cannot recall their name or home. Which
condition is most likely?
A) Delirium
B) Schizophrenia
C) Amnesia due to head trauma
D) Dissociative fugue
Correct Answer: D) Dissociative fugue
, Rationale: Dissociative fugue involves sudden, unexpected travel away from
home with inability to recall personal identity or important autobiographical
information. Delirium and schizophrenia do not typically cause total identity
loss.
5. A client with anorexia nervosa in group therapy says, “I realize that my fear of
gaining weight is irrational.” How should the nurse interpret this?
A) Effective therapy is occurring
B) The disorder is worsening
C) The client is being manipulative
D) The client needs immediate stabilization
Correct Answer: A) Effective therapy is occurring
Rationale: Recognizing that the fear of weight gain is irrational indicates
progress in eating disorder treatment. A statement such as “I will only eat if I
can exercise afterward” would indicate continued compensatory behavior.
6. Acute stress disorder symptoms must persist for at least which duration?
A) 1 day
B) 3 days
C) 2 weeks
D) 3 months
Correct Answer: B) 3 days
Nursing – Actual Q&A (GCN) (Updated PDF)
1. A client with post-traumatic stress disorder following a motor vehicle
accident is most likely to exhibit which finding?
A) Recurrent, intrusive distressing memories of the accident
B) Gratitude for surviving and optimism about the future
C) Repeatedly seeking out the accident scene
D) Complete loss of all memory of the accident
Correct Answer: A) Recurrent, intrusive distressing memories of the accident
Rationale: Intrusive symptoms, including recurrent involuntary memories,
flashbacks, and nightmares, are core features of PTSD. Avoidance, not seeking
out the trauma, is typical. Complete memory loss suggests dissociative amnesia.
2. A client with major depressive disorder states, “I don’t see the point in going
on.” What is the priority nursing action?
A) Encourage group therapy attendance
B) Assess for suicide risk, including plan and means
C) Teach about antidepressant side effects
D) Ensure adequate nutritional intake
Correct Answer: B) Assess for suicide risk, including plan and means
,Rationale: Safety is the priority in mental health nursing. A statement of
hopelessness indicates increased suicide risk. The nurse must directly assess
suicidal ideation, plan, and means, and initiate precautions if needed.
3. A client prescribed fluoxetine reports nausea, headache, and insomnia. Which
response is most appropriate?
A) Stop the medication immediately
B) Go to the emergency department
C) These are common side effects that often resolve in a few weeks
D) Switch to a different medication immediately
Correct Answer: C) These are common side effects that often resolve in a few
weeks
Rationale: Nausea, headache, and insomnia are common early side effects of
SSRIs and typically resolve within a few weeks. Clients should be encouraged to
continue the medication and not stop abruptly.
4. A client is found wandering and cannot recall their name or home. Which
condition is most likely?
A) Delirium
B) Schizophrenia
C) Amnesia due to head trauma
D) Dissociative fugue
Correct Answer: D) Dissociative fugue
, Rationale: Dissociative fugue involves sudden, unexpected travel away from
home with inability to recall personal identity or important autobiographical
information. Delirium and schizophrenia do not typically cause total identity
loss.
5. A client with anorexia nervosa in group therapy says, “I realize that my fear of
gaining weight is irrational.” How should the nurse interpret this?
A) Effective therapy is occurring
B) The disorder is worsening
C) The client is being manipulative
D) The client needs immediate stabilization
Correct Answer: A) Effective therapy is occurring
Rationale: Recognizing that the fear of weight gain is irrational indicates
progress in eating disorder treatment. A statement such as “I will only eat if I
can exercise afterward” would indicate continued compensatory behavior.
6. Acute stress disorder symptoms must persist for at least which duration?
A) 1 day
B) 3 days
C) 2 weeks
D) 3 months
Correct Answer: B) 3 days
