NUR 256 Exam 4 V2 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 4) | Galen College of Nursing
1. A client diagnosed with schizophrenia is prescribed clozapine. Which laboratory result
would be the nurse’s priority to monitor?
A. Blood urea nitrogen (BUN)
B. Absolute neutrophil count (ANC)
C. Serum potassium level
D. Hemoglobin A1c
Correct Answer: B
Explanation: Clozapine carries a high risk for agranulocytosis, a life-threatening reduction
in white blood cells. The nurse must monitor the absolute neutrophil count (ANC) weekly
for the first six months of treatment. If the ANC drops below 1,500/mm³, the medication is
typically discontinued to prevent severe infection.
2. A nurse is caring for a client with Bipolar I Disorder who is experiencing acute mania. Which
meal choice is most appropriate for this client?
A. Spaghetti and meatballs with a salad
B. Chicken nuggets, an apple, and a carton of milk
C. A bowl of vegetable soup and crackers
,D. Steak, baked potato, and green beans
Correct Answer: B
Explanation: Clients in an acute manic state have high energy levels and struggle to sit
down for a full meal. Providing finger foods like chicken nuggets and portable snacks
allows the client to maintain nutritional intake while moving. This intervention addresses
the risk of ‘imbalanced nutrition: less than body requirements’ common in manic episodes.
3. A client with Major Depressive Disorder is being started on phenelzine, an MAOI. Which
food should the nurse instruct the client to avoid?
A. Aged cheddar cheese
B. Fresh cottage cheese
C. Baked chicken breast
D. Steamed broccoli
Correct Answer: A
Explanation: Aged cheddar cheese contains high levels of tyramine, which can interact
with Monoamine Oxidase Inhibitors (MAOIs) like phenelzine. This interaction can lead to a
hypertensive crisis, a medical emergency characterized by severe high blood pressure and
headache. Clients must be educated to follow a low-tyramine diet strictly while on this class
of medication.
, 4. A client is admitted to the psychiatric unit with a lithium level of 1.8 mEq/L. Which
assessment finding should the nurse expect?
A. Increased appetite and weight gain
B. Coarse hand tremors and diarrhea
C. Hyperactivity and rapid speech
D. Urinary retention and constipation
Correct Answer: B
Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and a level of 1.8
mEq/L indicates moderate toxicity. Early signs of lithium toxicity include gastrointestinal
upset, coarse tremors, and confusion. The nurse should immediately withhold the
medication and prepare for interventions to lower the serum lithium level.
5. A nurse is conducting an admission assessment for a client with Borderline Personality
Disorder. Which behavior is the nurse most likely to observe?
A. Social isolation and lack of interest in others
B. Extreme perfectionism and orderliness
C. Excessive need for admiration and grandiosity
D. Rapidly shifting moods and ‘splitting’
Correct Answer: D
Health Nursing | Q&A with Rationale (NUR256
Exam 4) | Galen College of Nursing
1. A client diagnosed with schizophrenia is prescribed clozapine. Which laboratory result
would be the nurse’s priority to monitor?
A. Blood urea nitrogen (BUN)
B. Absolute neutrophil count (ANC)
C. Serum potassium level
D. Hemoglobin A1c
Correct Answer: B
Explanation: Clozapine carries a high risk for agranulocytosis, a life-threatening reduction
in white blood cells. The nurse must monitor the absolute neutrophil count (ANC) weekly
for the first six months of treatment. If the ANC drops below 1,500/mm³, the medication is
typically discontinued to prevent severe infection.
2. A nurse is caring for a client with Bipolar I Disorder who is experiencing acute mania. Which
meal choice is most appropriate for this client?
A. Spaghetti and meatballs with a salad
B. Chicken nuggets, an apple, and a carton of milk
C. A bowl of vegetable soup and crackers
,D. Steak, baked potato, and green beans
Correct Answer: B
Explanation: Clients in an acute manic state have high energy levels and struggle to sit
down for a full meal. Providing finger foods like chicken nuggets and portable snacks
allows the client to maintain nutritional intake while moving. This intervention addresses
the risk of ‘imbalanced nutrition: less than body requirements’ common in manic episodes.
3. A client with Major Depressive Disorder is being started on phenelzine, an MAOI. Which
food should the nurse instruct the client to avoid?
A. Aged cheddar cheese
B. Fresh cottage cheese
C. Baked chicken breast
D. Steamed broccoli
Correct Answer: A
Explanation: Aged cheddar cheese contains high levels of tyramine, which can interact
with Monoamine Oxidase Inhibitors (MAOIs) like phenelzine. This interaction can lead to a
hypertensive crisis, a medical emergency characterized by severe high blood pressure and
headache. Clients must be educated to follow a low-tyramine diet strictly while on this class
of medication.
, 4. A client is admitted to the psychiatric unit with a lithium level of 1.8 mEq/L. Which
assessment finding should the nurse expect?
A. Increased appetite and weight gain
B. Coarse hand tremors and diarrhea
C. Hyperactivity and rapid speech
D. Urinary retention and constipation
Correct Answer: B
Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and a level of 1.8
mEq/L indicates moderate toxicity. Early signs of lithium toxicity include gastrointestinal
upset, coarse tremors, and confusion. The nurse should immediately withhold the
medication and prepare for interventions to lower the serum lithium level.
5. A nurse is conducting an admission assessment for a client with Borderline Personality
Disorder. Which behavior is the nurse most likely to observe?
A. Social isolation and lack of interest in others
B. Extreme perfectionism and orderliness
C. Excessive need for admiration and grandiosity
D. Rapidly shifting moods and ‘splitting’
Correct Answer: D
