Page 1 of 30
NUR 253 – MENTAL HEALTH NURSING:
EXAM 3 PRACTICE TEST COMPLETE
QUESTIONS AND CORRECT ANSWERS
WITH DETAILED RATIONALES
Questions 1–50
1. The nurse is evaluating a client’s risk for suicide. Which client
statement indicates the highest risk?
• A. “Sometimes I feel like life is hard, but I would never hurt
myself.”
• B. “My family would be better off without me.”
• C. “I have a plan to take all my pills tonight after visiting
hours.”
• D. “I attempted suicide once, 10 years ago.”
A specific plan, access to means, and a stated
intent (time and method) indicates imminent risk. This is a
psychiatric emergency.
2. The nurse is caring for a client who is placed in seclusion after
aggressive behavior toward staff. Which action must the nurse
take first?
• A. Document the behavior that led to seclusion
• B. Assess the client’s physical and mental status
• C. Notify the client’s family
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• D. Obtain a written order from the provider
• Rationale: After placing a client in seclusion or restraints, the
nurse must first assess the client’s physical condition (vital
signs, injuries, elimination needs) and mental status. A provider
order must be obtained within a specific time frame (usually 1
hour).
3. The nurse is caring for a client with severe agitation who
requires chemical restraint. Which medication is most commonly
used for rapid tranquilization in a psychiatric emergency?
• A. Lithium (Lithobid)
• B. Haloperidol (Haldol) plus lorazepam (Ativan)
• C. Fluoxetine (Prozac)
• D. Bupropion (Wellbutrin)
Haloperidol (antipsychotic) and lorazepam
(benzodiazepine) are often combined for rapid tranquilization
of severe agitation or aggression. SSRIs and other medications
work too slowly.
4. The nurse is admitting an older adult client with delirium. The
client’s spouse asks, “Will my spouse recover completely?”
Which response is most accurate?
• A. “Once dementia starts, there is no recovery.”
• B. “Delirium is usually reversible once the underlying cause
is treated.”
• C. “Recovery is unlikely without long-term care placement.”
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• D. “Most clients with delirium will have permanent cognitive
deficits.”
• Rationale: Delirium is typically acute and reversible when the
underlying cause (infection, medications, metabolic
disturbance) is identified and treated. Dementia is irreversible.
5. The nurse is assessing an older adult client who is admitted from
a long-term care facility. The client is confused, agitated, and has
a temperature of 101.2°F (38.4°C). The family reports that the
client was at their baseline mental status yesterday. Which
condition is most likely?
• A. Alzheimer’s disease
• B. Delirium
• C. Vascular dementia
• D. Major depression
• Rationale: Delirium has an acute onset (hours to days), is often
caused by an underlying medical condition (e.g., infection), and
presents with fluctuating confusion, agitation, and altered
consciousness. Dementia develops gradually.
6. The nurse is caring for a client with moderate Alzheimer’s
disease who becomes agitated and tries to hit the nursing
assistant during a bath. What is the priority nursing action?
• A. Restrain the client’s arms
• B. Step back, speak calmly, and redirect the client to a
different activity
• C. Continue the bath quickly to finish the task
NUR 253 – MENTAL HEALTH NURSING:
EXAM 3 PRACTICE TEST COMPLETE
QUESTIONS AND CORRECT ANSWERS
WITH DETAILED RATIONALES
Questions 1–50
1. The nurse is evaluating a client’s risk for suicide. Which client
statement indicates the highest risk?
• A. “Sometimes I feel like life is hard, but I would never hurt
myself.”
• B. “My family would be better off without me.”
• C. “I have a plan to take all my pills tonight after visiting
hours.”
• D. “I attempted suicide once, 10 years ago.”
A specific plan, access to means, and a stated
intent (time and method) indicates imminent risk. This is a
psychiatric emergency.
2. The nurse is caring for a client who is placed in seclusion after
aggressive behavior toward staff. Which action must the nurse
take first?
• A. Document the behavior that led to seclusion
• B. Assess the client’s physical and mental status
• C. Notify the client’s family
, Page 2 of 30
• D. Obtain a written order from the provider
• Rationale: After placing a client in seclusion or restraints, the
nurse must first assess the client’s physical condition (vital
signs, injuries, elimination needs) and mental status. A provider
order must be obtained within a specific time frame (usually 1
hour).
3. The nurse is caring for a client with severe agitation who
requires chemical restraint. Which medication is most commonly
used for rapid tranquilization in a psychiatric emergency?
• A. Lithium (Lithobid)
• B. Haloperidol (Haldol) plus lorazepam (Ativan)
• C. Fluoxetine (Prozac)
• D. Bupropion (Wellbutrin)
Haloperidol (antipsychotic) and lorazepam
(benzodiazepine) are often combined for rapid tranquilization
of severe agitation or aggression. SSRIs and other medications
work too slowly.
4. The nurse is admitting an older adult client with delirium. The
client’s spouse asks, “Will my spouse recover completely?”
Which response is most accurate?
• A. “Once dementia starts, there is no recovery.”
• B. “Delirium is usually reversible once the underlying cause
is treated.”
• C. “Recovery is unlikely without long-term care placement.”
, Page 3 of 30
• D. “Most clients with delirium will have permanent cognitive
deficits.”
• Rationale: Delirium is typically acute and reversible when the
underlying cause (infection, medications, metabolic
disturbance) is identified and treated. Dementia is irreversible.
5. The nurse is assessing an older adult client who is admitted from
a long-term care facility. The client is confused, agitated, and has
a temperature of 101.2°F (38.4°C). The family reports that the
client was at their baseline mental status yesterday. Which
condition is most likely?
• A. Alzheimer’s disease
• B. Delirium
• C. Vascular dementia
• D. Major depression
• Rationale: Delirium has an acute onset (hours to days), is often
caused by an underlying medical condition (e.g., infection), and
presents with fluctuating confusion, agitation, and altered
consciousness. Dementia develops gradually.
6. The nurse is caring for a client with moderate Alzheimer’s
disease who becomes agitated and tries to hit the nursing
assistant during a bath. What is the priority nursing action?
• A. Restrain the client’s arms
• B. Step back, speak calmly, and redirect the client to a
different activity
• C. Continue the bath quickly to finish the task
