NUR 256 Exam 2 V2 | 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 who is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Instruct the client to use abdominal breathing techniques.
B. Administer a PRN dose of lorazepam.
C. Ask the client to describe what triggered the attack.
D. Stay with the client and remain quiet.
Correct Answer: D
Explanation: Safety and presence are the priorities during a panic-level anxiety episode.
Staying with the client provides a sense of security and ensures their physical safety while
they are unable to process information. Once the client is calmer, breathing techniques or
medication can be addressed, but immediate presence is the first nursing action.
2. A client with Major Depressive Disorder (MDD) has been taking an SSRI for two weeks. The
client suddenly reports feeling ‘much better’ and has significantly more energy. Which action
is the priority for the nurse?
A. Document the positive response to the medication.
B. Prepare the client for discharge planning.
,C. Initiate suicide precautions and increase monitoring.
D. Decrease the frequency of vital sign checks.
Correct Answer: C
Explanation: When a severely depressed client suddenly exhibits a surge in energy or
improvement in mood, the risk for suicide increases. This is because the client may now
have the physical energy required to carry out a suicide plan they previously lacked the
energy to execute. The nurse must immediately assess for suicidal ideation and implement
safety measures.
3. A nurse is educating a client who has a new prescription for phenelzine. Which food choice
by the client indicates a need for further teaching?
A. Grilled chicken breast with steamed broccoli
B. Fresh apple slices with peanut butter
C. A pepperoni and aged cheddar cheese platter
D. Baked potato with sour cream and chives
Correct Answer: C
Explanation: Phenelzine is an MAOI, which requires a tyramine-restricted diet to prevent
hypertensive crisis. Aged cheeses, pepperoni, salami, and fermented foods are high in
tyramine and must be avoided. Fresh meats and fruits are generally safe for clients on this
medication class.
, 4. A client is admitted to the psychiatric unit with a lithium level of 1.8 mEq/L. Which clinical
finding should the nurse expect to observe?
A. Increased appetite and weight gain
B. Fine hand tremors and mild thirst
C. Vomiting, diarrhea, and coarse tremors
D. Seizures and cardiovascular collapse
Correct Answer: C
Explanation: A lithium level of 1.8 mEq/L indicates early to moderate toxicity, as the
therapeutic range is typically 0.6 to 1.2 mEq/L. Manifestations of toxicity include
gastrointestinal upset (nausea, vomiting, diarrhea), coarse hand tremors, and mental
confusion. Seizures and collapse typically occur at levels above 2.5 mEq/L.
5. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. Which of the
following snack choices is most appropriate for this client?
A. A bowl of chicken noodle soup
B. Spaghetti with meatballs
C. A cheeseburger and an apple
D. A cup of yogurt with a spoon
Correct Answer: C
Health Nursing | Q&A with Rationale (NUR256
Exam 2) | Galen College of Nursing
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Instruct the client to use abdominal breathing techniques.
B. Administer a PRN dose of lorazepam.
C. Ask the client to describe what triggered the attack.
D. Stay with the client and remain quiet.
Correct Answer: D
Explanation: Safety and presence are the priorities during a panic-level anxiety episode.
Staying with the client provides a sense of security and ensures their physical safety while
they are unable to process information. Once the client is calmer, breathing techniques or
medication can be addressed, but immediate presence is the first nursing action.
2. A client with Major Depressive Disorder (MDD) has been taking an SSRI for two weeks. The
client suddenly reports feeling ‘much better’ and has significantly more energy. Which action
is the priority for the nurse?
A. Document the positive response to the medication.
B. Prepare the client for discharge planning.
,C. Initiate suicide precautions and increase monitoring.
D. Decrease the frequency of vital sign checks.
Correct Answer: C
Explanation: When a severely depressed client suddenly exhibits a surge in energy or
improvement in mood, the risk for suicide increases. This is because the client may now
have the physical energy required to carry out a suicide plan they previously lacked the
energy to execute. The nurse must immediately assess for suicidal ideation and implement
safety measures.
3. A nurse is educating a client who has a new prescription for phenelzine. Which food choice
by the client indicates a need for further teaching?
A. Grilled chicken breast with steamed broccoli
B. Fresh apple slices with peanut butter
C. A pepperoni and aged cheddar cheese platter
D. Baked potato with sour cream and chives
Correct Answer: C
Explanation: Phenelzine is an MAOI, which requires a tyramine-restricted diet to prevent
hypertensive crisis. Aged cheeses, pepperoni, salami, and fermented foods are high in
tyramine and must be avoided. Fresh meats and fruits are generally safe for clients on this
medication class.
, 4. A client is admitted to the psychiatric unit with a lithium level of 1.8 mEq/L. Which clinical
finding should the nurse expect to observe?
A. Increased appetite and weight gain
B. Fine hand tremors and mild thirst
C. Vomiting, diarrhea, and coarse tremors
D. Seizures and cardiovascular collapse
Correct Answer: C
Explanation: A lithium level of 1.8 mEq/L indicates early to moderate toxicity, as the
therapeutic range is typically 0.6 to 1.2 mEq/L. Manifestations of toxicity include
gastrointestinal upset (nausea, vomiting, diarrhea), coarse hand tremors, and mental
confusion. Seizures and collapse typically occur at levels above 2.5 mEq/L.
5. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. Which of the
following snack choices is most appropriate for this client?
A. A bowl of chicken noodle soup
B. Spaghetti with meatballs
C. A cheeseburger and an apple
D. A cup of yogurt with a spoon
Correct Answer: C
