NUR 256 Final Exam V2 | 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 has schizophrenia and is experiencing auditory
hallucinations. Which of the following responses should the nurse make?
A. ‘I know you hear voices, but they are not real.’
B. ‘Tell the voices to go away and leave you alone.’
C. ‘Why do you think you are hearing those voices right now?’
D. ‘I don’t hear the voices, but I understand that they are real to you.’
Correct Answer: D
Explanation: This response acknowledges the client’s perception without validating the
hallucination as reality. It maintains a therapeutic relationship by demonstrating empathy
while staying grounded in the nurse’s own reality. Using ‘why’ questions should be avoided
as it can be perceived as accusatory or challenging.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following instructions should the nurse include in the teaching?
A. Limit sodium intake to less than 2 grams per day.
B. Drink 2 to 3 liters of fluid daily.
C. Take the medication on an empty stomach.
,D. Stop taking the medication if fine hand tremors occur.
Correct Answer: B
Explanation: Lithium is a salt, and maintaining adequate fluid intake is crucial to prevent
toxicity. Decreased sodium intake can cause the kidneys to retain lithium, leading to toxic
levels. Fine hand tremors are a common side effect, but the medication should not be
stopped without consulting a provider.
3. A nurse is reviewing the laboratory results of a client who is taking clozapine. Which of the
following results should the nurse report to the provider immediately?
A. Fasting blood glucose 110 mg/dL
B. Platelet count 150,000/mm³
C. White blood cell (WBC) count 2,500/mm³
D. Potassium 3.8 mEq/L
Correct Answer: C
Explanation: Clozapine carries a high risk for agranulocytosis, which is a dangerous
decrease in the WBC count. A WBC count below 3,000/mm³ requires immediate
notification and discontinuation of the drug. The other values are within or near normal
limits and do not represent the acute life-threatening risk associated with clozapine.
4. Which ethical principle is a nurse demonstrating when they spend extra time with a client
who is anxious and needs support?
A. Autonomy
, B. Justice
C. Veracity
D. Beneficence
Correct Answer: D
Explanation: Beneficence refers to the duty to act in ways that benefit others and promote
the well-being of the client. Spending extra time with an anxious client is a direct
application of this principle. Autonomy refers to the client’s right to make their own
decisions.
5. A client with Borderline Personality Disorder (BPD) is praised by the nurse during the
morning shift, but later that day, the client tells the evening nurse that the morning nurse is
‘incompetent.’ This behavior is known as:
A. Splitting
B. Projection
C. Reaction formation
D. Undoing
Correct Answer: A
Explanation: Splitting is a common defense mechanism in clients with BPD where they
perceive individuals as either all good or all bad. It reflects an inability to integrate the
Mental Health Nursing | Q&A with Rationale
(NUR256 Final Exam) | Galen College of Nursing
1. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following responses should the nurse make?
A. ‘I know you hear voices, but they are not real.’
B. ‘Tell the voices to go away and leave you alone.’
C. ‘Why do you think you are hearing those voices right now?’
D. ‘I don’t hear the voices, but I understand that they are real to you.’
Correct Answer: D
Explanation: This response acknowledges the client’s perception without validating the
hallucination as reality. It maintains a therapeutic relationship by demonstrating empathy
while staying grounded in the nurse’s own reality. Using ‘why’ questions should be avoided
as it can be perceived as accusatory or challenging.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following instructions should the nurse include in the teaching?
A. Limit sodium intake to less than 2 grams per day.
B. Drink 2 to 3 liters of fluid daily.
C. Take the medication on an empty stomach.
,D. Stop taking the medication if fine hand tremors occur.
Correct Answer: B
Explanation: Lithium is a salt, and maintaining adequate fluid intake is crucial to prevent
toxicity. Decreased sodium intake can cause the kidneys to retain lithium, leading to toxic
levels. Fine hand tremors are a common side effect, but the medication should not be
stopped without consulting a provider.
3. A nurse is reviewing the laboratory results of a client who is taking clozapine. Which of the
following results should the nurse report to the provider immediately?
A. Fasting blood glucose 110 mg/dL
B. Platelet count 150,000/mm³
C. White blood cell (WBC) count 2,500/mm³
D. Potassium 3.8 mEq/L
Correct Answer: C
Explanation: Clozapine carries a high risk for agranulocytosis, which is a dangerous
decrease in the WBC count. A WBC count below 3,000/mm³ requires immediate
notification and discontinuation of the drug. The other values are within or near normal
limits and do not represent the acute life-threatening risk associated with clozapine.
4. Which ethical principle is a nurse demonstrating when they spend extra time with a client
who is anxious and needs support?
A. Autonomy
, B. Justice
C. Veracity
D. Beneficence
Correct Answer: D
Explanation: Beneficence refers to the duty to act in ways that benefit others and promote
the well-being of the client. Spending extra time with an anxious client is a direct
application of this principle. Autonomy refers to the client’s right to make their own
decisions.
5. A client with Borderline Personality Disorder (BPD) is praised by the nurse during the
morning shift, but later that day, the client tells the evening nurse that the morning nurse is
‘incompetent.’ This behavior is known as:
A. Splitting
B. Projection
C. Reaction formation
D. Undoing
Correct Answer: A
Explanation: Splitting is a common defense mechanism in clients with BPD where they
perceive individuals as either all good or all bad. It reflects an inability to integrate the
