NUR 256 Final Exam V3 | 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 who is experiencing a manic episode. Which of the following
nursing interventions is the priority?
A. Encouraging the client to participate in group exercise.
B. Providing high-calorie finger foods that can be eaten while walking.
C. Setting strict limits on the client’s behavior with consequences.
D. Administering a sedative every four hours as needed.
Correct Answer: B
Explanation: Clients in a manic state often have difficulty sitting down for meals and may
experience significant weight loss and exhaustion. Providing high-calorie finger foods
allows the client to maintain nutritional intake while on the move. This intervention
addresses the physiological need for energy and prevents physical exhaustion during the
manic phase.
2. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Fine hand tremors and nausea.
B. Seizures and hypotension.
,C. Severe hypotension and polyuria.
D. Ataxia and blurred vision.
Correct Answer: A
Explanation: Early signs of lithium toxicity typically include gastrointestinal upset, fine
hand tremors, and muscle weakness. As levels rise, these symptoms progress to more
severe neurological and cardiovascular issues. The nurse must monitor serum lithium
levels closely to ensure they remain within the therapeutic range of 0.6 to 1.2 mEq/L.
3. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following
actions is the nurse’s priority?
A. Encouraging the client to attend a support group.
B. Asking the client to sign a ‘no-suicide’ contract.
C. Administering an antidepressant medication.
D. Initiating one-on-one constant observation.
Correct Answer: D
Explanation: Safety is always the primary concern for a client who has recently attempted
suicide or expresses suicidal ideation. Constant one-on-one observation ensures the client’s
immediate physical safety by preventing further self-harm attempts. While other
interventions like medication and contracting are useful, they do not replace the necessity
of direct supervision in an acute crisis.
,4. A nurse is providing teaching to a client who has a new prescription for phenelzine. Which
of the following foods should the nurse instruct the client to avoid?
A. Fresh green leafy vegetables.
B. Whole grain breads and cereals.
C. Aged cheeses and cured meats.
D. Citrus fruits and juices.
Correct Answer: C
Explanation: Phenelzine is a monoamine oxidase inhibitor (MAOI) that requires a
tyramine-restricted diet to prevent hypertensive crisis. Aged cheeses, cured meats, and
fermented products are high in tyramine and can lead to dangerous elevations in blood
pressure. The nurse must provide comprehensive education on dietary restrictions to
ensure client safety during pharmacotherapy.
5. Which therapeutic communication technique is being used when the nurse says, ‘You say
you are feeling angry, but you are smiling’?
A. Restating
B. Summarizing
C. Reflecting
D. Confrontation
Correct Answer: D
, Explanation: Confrontation is a technique used to point out discrepancies between a
client’s verbal statements and their non-verbal behavior. This helps the client become
aware of their inconsistent communication and encourages them to explore their true
feelings. It should be used judiciously within a strong therapeutic relationship to avoid
becoming defensive or non-therapeutic.
6. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which of the following responses is appropriate?
A. ‘I don’t hear the voices, but I can see that they are upsetting you.’
B. ‘What are the voices telling you to do right now?’
C. ‘You know that the voices are not real, right?’
D. ‘Tell the voices to go away and leave you alone.’
Correct Answer: A
Explanation: This response acknowledges the client’s experience without validating the
hallucination as reality. By expressing that the nurse does not hear the voices, the nurse
provides a reality check while still showing empathy for the client’s distress. This approach
helps maintain a therapeutic connection without reinforcing the delusional or
hallucinatory process.
7. A client is exhibiting signs of alcohol withdrawal. Which medication should the nurse
anticipate administering to manage these symptoms?
A. Lorazepam
Mental Health Nursing | Q&A with Rationale
(NUR256 Final Exam) | Galen College of Nursing
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
nursing interventions is the priority?
A. Encouraging the client to participate in group exercise.
B. Providing high-calorie finger foods that can be eaten while walking.
C. Setting strict limits on the client’s behavior with consequences.
D. Administering a sedative every four hours as needed.
Correct Answer: B
Explanation: Clients in a manic state often have difficulty sitting down for meals and may
experience significant weight loss and exhaustion. Providing high-calorie finger foods
allows the client to maintain nutritional intake while on the move. This intervention
addresses the physiological need for energy and prevents physical exhaustion during the
manic phase.
2. A nurse is assessing a client for lithium toxicity. Which of the following findings should the
nurse identify as an early sign of toxicity?
A. Fine hand tremors and nausea.
B. Seizures and hypotension.
,C. Severe hypotension and polyuria.
D. Ataxia and blurred vision.
Correct Answer: A
Explanation: Early signs of lithium toxicity typically include gastrointestinal upset, fine
hand tremors, and muscle weakness. As levels rise, these symptoms progress to more
severe neurological and cardiovascular issues. The nurse must monitor serum lithium
levels closely to ensure they remain within the therapeutic range of 0.6 to 1.2 mEq/L.
3. A client is admitted to the psychiatric unit after a suicide attempt. Which of the following
actions is the nurse’s priority?
A. Encouraging the client to attend a support group.
B. Asking the client to sign a ‘no-suicide’ contract.
C. Administering an antidepressant medication.
D. Initiating one-on-one constant observation.
Correct Answer: D
Explanation: Safety is always the primary concern for a client who has recently attempted
suicide or expresses suicidal ideation. Constant one-on-one observation ensures the client’s
immediate physical safety by preventing further self-harm attempts. While other
interventions like medication and contracting are useful, they do not replace the necessity
of direct supervision in an acute crisis.
,4. A nurse is providing teaching to a client who has a new prescription for phenelzine. Which
of the following foods should the nurse instruct the client to avoid?
A. Fresh green leafy vegetables.
B. Whole grain breads and cereals.
C. Aged cheeses and cured meats.
D. Citrus fruits and juices.
Correct Answer: C
Explanation: Phenelzine is a monoamine oxidase inhibitor (MAOI) that requires a
tyramine-restricted diet to prevent hypertensive crisis. Aged cheeses, cured meats, and
fermented products are high in tyramine and can lead to dangerous elevations in blood
pressure. The nurse must provide comprehensive education on dietary restrictions to
ensure client safety during pharmacotherapy.
5. Which therapeutic communication technique is being used when the nurse says, ‘You say
you are feeling angry, but you are smiling’?
A. Restating
B. Summarizing
C. Reflecting
D. Confrontation
Correct Answer: D
, Explanation: Confrontation is a technique used to point out discrepancies between a
client’s verbal statements and their non-verbal behavior. This helps the client become
aware of their inconsistent communication and encourages them to explore their true
feelings. It should be used judiciously within a strong therapeutic relationship to avoid
becoming defensive or non-therapeutic.
6. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which of the following responses is appropriate?
A. ‘I don’t hear the voices, but I can see that they are upsetting you.’
B. ‘What are the voices telling you to do right now?’
C. ‘You know that the voices are not real, right?’
D. ‘Tell the voices to go away and leave you alone.’
Correct Answer: A
Explanation: This response acknowledges the client’s experience without validating the
hallucination as reality. By expressing that the nurse does not hear the voices, the nurse
provides a reality check while still showing empathy for the client’s distress. This approach
helps maintain a therapeutic connection without reinforcing the delusional or
hallucinatory process.
7. A client is exhibiting signs of alcohol withdrawal. Which medication should the nurse
anticipate administering to manage these symptoms?
A. Lorazepam
