NUR 256 Exam 2 V3 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 2) | Galen College of Nursing
1. A nurse is assessing a client with Major Depressive Disorder (MDD). Which clinical
manifestation should the nurse identify as a vegetative sign of depression?
A. Feelings of hopelessness and worthlessness
B. Psychomotor agitation and pacing
C. Changes in sleep patterns and appetite
D. Recurring thoughts of self-harm
Correct Answer: C
Explanation: Vegetative signs of depression refer to alterations in activities necessary to
support physical life and growth. These include changes in eating patterns, sleep, bowel
habits, and libido. Identifying these is crucial for physical health maintenance during a
depressive episode.
2. A client is prescribed a Monoamine Oxidase Inhibitor (MAOI) for treatment-resistant
depression. Which food choice indicates the client understands the necessary dietary
restrictions?
A. Avocado toast with smoked salmon
B. Pepperoni pizza with extra cheese
,C. Aged cheddar cheese and crackers
D. Grilled chicken breast with steamed broccoli
Correct Answer: D
Explanation: Clients taking MAOIs must follow a low-tyramine diet to avoid a
hypertensive crisis. Foods like aged cheeses, cured meats, and fermented products are high
in tyramine and must be avoided. Grilled chicken and fresh vegetables are safe options for
these patients.
3. A nurse is caring for a client experiencing a manic episode of Bipolar I Disorder. Which
nursing intervention is the highest priority?
A. Engaging the client in group therapy sessions
B. Setting limits on the client’s intrusive behavior
C. Encouraging the client to express feelings of anger
D. Providing high-calorie finger foods for nutrition
Correct Answer: D
Explanation: During a manic episode, physical needs often take priority due to extreme
hyperactivity and lack of focus on self-care. Providing high-calorie finger foods allows the
client to maintain nutrition while on the move. Safety and physiological stability are the
primary nursing concerns.
, 4. A client’s lithium level is reported as 1.8 mEq/L. Which action should the nurse take first?
A. Hold the dose and notify the healthcare provider
B. Administer the next scheduled dose of lithium
C. Encourage the client to increase fluid intake
D. Repeat the lab draw to verify the results
Correct Answer: A
Explanation: A lithium level of 1.8 mEq/L is considered toxic, as the therapeutic range is
typically 0.6 to 1.2 mEq/L. The nurse must immediately hold the medication to prevent
further toxicity and notify the provider for intervention. Signs of toxicity include tremors,
confusion, and ataxia.
5. Which assessment finding is most characteristic of Anorexia Nervosa rather than Bulimia
Nervosa?
A. Dental caries and erosion of tooth enamel
B. Body weight significantly below the ideal range
C. Parotid gland swelling and calluses on knuckles
D. Normal or slightly overweight body mass index
Correct Answer: B
Explanation: Anorexia Nervosa is primarily characterized by a refusal to maintain a
minimally normal body weight and an intense fear of gaining weight. While bulimia
Health Nursing | Q&A with Rationale (NUR256
Exam 2) | Galen College of Nursing
1. A nurse is assessing a client with Major Depressive Disorder (MDD). Which clinical
manifestation should the nurse identify as a vegetative sign of depression?
A. Feelings of hopelessness and worthlessness
B. Psychomotor agitation and pacing
C. Changes in sleep patterns and appetite
D. Recurring thoughts of self-harm
Correct Answer: C
Explanation: Vegetative signs of depression refer to alterations in activities necessary to
support physical life and growth. These include changes in eating patterns, sleep, bowel
habits, and libido. Identifying these is crucial for physical health maintenance during a
depressive episode.
2. A client is prescribed a Monoamine Oxidase Inhibitor (MAOI) for treatment-resistant
depression. Which food choice indicates the client understands the necessary dietary
restrictions?
A. Avocado toast with smoked salmon
B. Pepperoni pizza with extra cheese
,C. Aged cheddar cheese and crackers
D. Grilled chicken breast with steamed broccoli
Correct Answer: D
Explanation: Clients taking MAOIs must follow a low-tyramine diet to avoid a
hypertensive crisis. Foods like aged cheeses, cured meats, and fermented products are high
in tyramine and must be avoided. Grilled chicken and fresh vegetables are safe options for
these patients.
3. A nurse is caring for a client experiencing a manic episode of Bipolar I Disorder. Which
nursing intervention is the highest priority?
A. Engaging the client in group therapy sessions
B. Setting limits on the client’s intrusive behavior
C. Encouraging the client to express feelings of anger
D. Providing high-calorie finger foods for nutrition
Correct Answer: D
Explanation: During a manic episode, physical needs often take priority due to extreme
hyperactivity and lack of focus on self-care. Providing high-calorie finger foods allows the
client to maintain nutrition while on the move. Safety and physiological stability are the
primary nursing concerns.
, 4. A client’s lithium level is reported as 1.8 mEq/L. Which action should the nurse take first?
A. Hold the dose and notify the healthcare provider
B. Administer the next scheduled dose of lithium
C. Encourage the client to increase fluid intake
D. Repeat the lab draw to verify the results
Correct Answer: A
Explanation: A lithium level of 1.8 mEq/L is considered toxic, as the therapeutic range is
typically 0.6 to 1.2 mEq/L. The nurse must immediately hold the medication to prevent
further toxicity and notify the provider for intervention. Signs of toxicity include tremors,
confusion, and ataxia.
5. Which assessment finding is most characteristic of Anorexia Nervosa rather than Bulimia
Nervosa?
A. Dental caries and erosion of tooth enamel
B. Body weight significantly below the ideal range
C. Parotid gland swelling and calluses on knuckles
D. Normal or slightly overweight body mass index
Correct Answer: B
Explanation: Anorexia Nervosa is primarily characterized by a refusal to maintain a
minimally normal body weight and an intense fear of gaining weight. While bulimia
