NUR 256 Exam 2 V1 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 2) | Galen College of Nursing
1. A nurse is caring for a client with Bipolar I disorder who is experiencing a manic episode.
The client is moving rapidly, talking incessantly, and has not slept in 24 hours. Which
nutritional intervention is most appropriate?
A. Restrict fluids to prevent frequent trips to the bathroom.
B. Seat the client in the dining room with other patients for social support.
C. Encourage the client to sit still and finish a three-course meal.
D. Provide the client with high-calorie, high-protein finger foods.
Correct Answer: D
Explanation: Clients in a manic state are often too hyperactive to sit down for traditional
meals. Providing high-calorie finger foods allows them to eat while on the move,
maintaining nutritional intake. This intervention prevents exhaustion and weight loss
associated with the increased metabolic demands of mania.
2. A client is being started on Lithium carbonate for the treatment of Bipolar Disorder. The
nurse should instruct the client to maintain a consistent intake of which substance?
A. Potassium
B. Calcium
,C. Magnesium
D. Sodium
Correct Answer: D
Explanation: Lithium is a salt and is handled by the kidneys in a manner similar to sodium.
If sodium levels drop, the kidneys will retain lithium to compensate, leading to toxicity.
Therefore, the client must maintain a consistent salt and fluid intake to keep lithium levels
stable.
3. A client diagnosed with Schizophrenia is experiencing auditory hallucinations, telling the
nurse, ‘The voices are telling me to hurt myself.’ Which is the priority nursing action?
A. Ask the client to describe what the voices look like.
B. Tell the client that the voices are not real and to ignore them.
C. Administer a PRN dose of an anti-anxiety medication.
D. Implement suicide precautions and provide one-to-one observation.
Correct Answer: D
Explanation: Safety is the highest priority when a client reports command hallucinations
to self-harm. The nurse must immediately implement safety protocols to prevent the client
from acting on these commands. One-to-one observation ensures the client is never alone
during this high-risk period.
, 4. Which finding should a nurse recognize as a negative symptom of Schizophrenia?
A. Delusions of grandeur
B. Flat affect and social withdrawal
C. Auditory hallucinations
D. Echolalia and disorganized speech
Correct Answer: B
Explanation: Negative symptoms represent a loss or absence of normal function, such as
flat affect, alogia, and avolition. Positive symptoms, such as delusions and hallucinations,
are additions to normal behavior. Recognizing negative symptoms is crucial because they
often respond less effectively to traditional antipsychotics than positive symptoms.
5. A nurse is monitoring a client who recently started taking Haloperidol. The client is
experiencing muscle rigidity, high fever, and autonomic instability. What condition should the
nurse suspect?
A. Neuroleptic Malignant Syndrome (NMS)
B. Tardive Dyskinesia
C. Serotonin Syndrome
D. Agranulocytosis
Correct Answer: A
Health Nursing | Q&A with Rationale (NUR256
Exam 2) | Galen College of Nursing
1. A nurse is caring for a client with Bipolar I disorder who is experiencing a manic episode.
The client is moving rapidly, talking incessantly, and has not slept in 24 hours. Which
nutritional intervention is most appropriate?
A. Restrict fluids to prevent frequent trips to the bathroom.
B. Seat the client in the dining room with other patients for social support.
C. Encourage the client to sit still and finish a three-course meal.
D. Provide the client with high-calorie, high-protein finger foods.
Correct Answer: D
Explanation: Clients in a manic state are often too hyperactive to sit down for traditional
meals. Providing high-calorie finger foods allows them to eat while on the move,
maintaining nutritional intake. This intervention prevents exhaustion and weight loss
associated with the increased metabolic demands of mania.
2. A client is being started on Lithium carbonate for the treatment of Bipolar Disorder. The
nurse should instruct the client to maintain a consistent intake of which substance?
A. Potassium
B. Calcium
,C. Magnesium
D. Sodium
Correct Answer: D
Explanation: Lithium is a salt and is handled by the kidneys in a manner similar to sodium.
If sodium levels drop, the kidneys will retain lithium to compensate, leading to toxicity.
Therefore, the client must maintain a consistent salt and fluid intake to keep lithium levels
stable.
3. A client diagnosed with Schizophrenia is experiencing auditory hallucinations, telling the
nurse, ‘The voices are telling me to hurt myself.’ Which is the priority nursing action?
A. Ask the client to describe what the voices look like.
B. Tell the client that the voices are not real and to ignore them.
C. Administer a PRN dose of an anti-anxiety medication.
D. Implement suicide precautions and provide one-to-one observation.
Correct Answer: D
Explanation: Safety is the highest priority when a client reports command hallucinations
to self-harm. The nurse must immediately implement safety protocols to prevent the client
from acting on these commands. One-to-one observation ensures the client is never alone
during this high-risk period.
, 4. Which finding should a nurse recognize as a negative symptom of Schizophrenia?
A. Delusions of grandeur
B. Flat affect and social withdrawal
C. Auditory hallucinations
D. Echolalia and disorganized speech
Correct Answer: B
Explanation: Negative symptoms represent a loss or absence of normal function, such as
flat affect, alogia, and avolition. Positive symptoms, such as delusions and hallucinations,
are additions to normal behavior. Recognizing negative symptoms is crucial because they
often respond less effectively to traditional antipsychotics than positive symptoms.
5. A nurse is monitoring a client who recently started taking Haloperidol. The client is
experiencing muscle rigidity, high fever, and autonomic instability. What condition should the
nurse suspect?
A. Neuroleptic Malignant Syndrome (NMS)
B. Tardive Dyskinesia
C. Serotonin Syndrome
D. Agranulocytosis
Correct Answer: A
