NUR 256 Final Exam V1 | NUR 256 Concepts of
Mental Health Nursing | Q&A with Rationale
(NUR256 Final Exam) | Galen College of Nursing
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
hurt themselves. What is the priority nursing action?
A. Place the client in a seclusion room for safety.
B. Administer a PRN dose of haloperidol.
C. Assess the client for a specific suicide plan.
D. Ask the client to describe the voices in detail.
Correct Answer: C
Explanation: The safety of the client is the highest priority when command hallucinations
are present. Assessing for a specific plan helps determine the immediate level of lethality
and risk. This intervention allows the nurse to implement appropriate suicide precautions
based on the assessment findings.
2. A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value should
the nurse monitor most closely to prevent toxicity?
A. Serum sodium levels
B. Serum potassium levels
C. Blood urea nitrogen (BUN)
,D. Serum glucose levels
Correct Answer: A
Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in the
body. When sodium levels are low, the kidneys retain lithium, which can lead to toxic levels
in the blood. Educating the client on maintaining a consistent sodium intake is a critical
component of lithium therapy management.
3. A client with a history of alcohol use disorder is admitted and begins to show signs of
tremors, tachycardia, and diaphoresis. Which medication should the nurse expect to
administer?
A. Lorazepam
B. Naltrexone
C. Disulfiram
D. Methadone
Correct Answer: A
Explanation: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help prevent seizures and delirium tremens by
providing cross-tolerance with alcohol. This medication stabilizes the central nervous
system during the detoxification process.
, 4. A nurse is conducting a mental status examination (MSE) on a new client. Which finding
describes the client’s ‘affect’?
A. The client reports feeling ‘sad and hopeless.’
B. The client is wearing mismatched clothing.
C. The client believes the FBI is tracking them.
D. The client exhibits a flat facial expression.
Correct Answer: D
Explanation: Affect refers to the external, observable emotional response of a client, such
as a flat or blunted expression. Mood, by contrast, is the subjective emotional state
reported by the client. Identifying affect is a key component of the objective portion of the
mental status exam.
5. Which defense mechanism is a client using when they yell at their spouse after having a
stressful day at work with their manager?
A. Displacement
B. Reaction Formation
C. Projection
D. Sublimation
Correct Answer: A
Mental Health Nursing | Q&A with Rationale
(NUR256 Final Exam) | Galen College of Nursing
1. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
hurt themselves. What is the priority nursing action?
A. Place the client in a seclusion room for safety.
B. Administer a PRN dose of haloperidol.
C. Assess the client for a specific suicide plan.
D. Ask the client to describe the voices in detail.
Correct Answer: C
Explanation: The safety of the client is the highest priority when command hallucinations
are present. Assessing for a specific plan helps determine the immediate level of lethality
and risk. This intervention allows the nurse to implement appropriate suicide precautions
based on the assessment findings.
2. A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value should
the nurse monitor most closely to prevent toxicity?
A. Serum sodium levels
B. Serum potassium levels
C. Blood urea nitrogen (BUN)
,D. Serum glucose levels
Correct Answer: A
Explanation: Lithium is a salt, and its excretion is closely linked to sodium levels in the
body. When sodium levels are low, the kidneys retain lithium, which can lead to toxic levels
in the blood. Educating the client on maintaining a consistent sodium intake is a critical
component of lithium therapy management.
3. A client with a history of alcohol use disorder is admitted and begins to show signs of
tremors, tachycardia, and diaphoresis. Which medication should the nurse expect to
administer?
A. Lorazepam
B. Naltrexone
C. Disulfiram
D. Methadone
Correct Answer: A
Explanation: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help prevent seizures and delirium tremens by
providing cross-tolerance with alcohol. This medication stabilizes the central nervous
system during the detoxification process.
, 4. A nurse is conducting a mental status examination (MSE) on a new client. Which finding
describes the client’s ‘affect’?
A. The client reports feeling ‘sad and hopeless.’
B. The client is wearing mismatched clothing.
C. The client believes the FBI is tracking them.
D. The client exhibits a flat facial expression.
Correct Answer: D
Explanation: Affect refers to the external, observable emotional response of a client, such
as a flat or blunted expression. Mood, by contrast, is the subjective emotional state
reported by the client. Identifying affect is a key component of the objective portion of the
mental status exam.
5. Which defense mechanism is a client using when they yell at their spouse after having a
stressful day at work with their manager?
A. Displacement
B. Reaction Formation
C. Projection
D. Sublimation
Correct Answer: A
