,NSG3450/NSG 3450 Exam 3 | Mental Health
Nursing | Galen College | 26/27 Updated
(PDF)
1. A nurse is planning care for a client experiencing acute mania. Which intervention is most effective
for managing the client's excessive physical activity and ensuring safety?
A) Encouraging the client to participate in competitive sports
B) Allowing the client to wander freely to expend energy
C) Providing structured, low-stimulation activities with rest periods
D) Assigning the client to lead a high-energy exercise group
Correct Answer: Providing structured, low-stimulation activities with rest periods
Rationale: Structured activities with rest periods help channel energy constructively while preventing
exhaustion. Competitive sports may increase agitation, free wandering poses safety risks, and leading
a high-energy group is inappropriate for a manic client who lacks insight and judgment.
2. A client with major depressive disorder tells the nurse, "I am worthless and nothing I do matters."
Which nursing intervention is most therapeutic in response to this statement?
A) Reassuring the client that things will get better soon
B) Exploring the reasons behind the client's feelings of worthlessness
C) Encouraging the client to list personal strengths and accomplishments
D) Redirecting the conversation to a less negative topic
Correct Answer: Encouraging the client to list personal strengths and accomplishments
Rationale: Cognitive restructuring helps challenge negative self-perceptions by focusing on objective
evidence of worth. Reassurance may feel dismissive, exploring reasons may reinforce rumination, and
redirection avoids addressing the core issue.
,3. A client with bipolar disorder who is taking lithium has a serum level of 1.8 mEq/L drawn 12 hours
after the last dose. Which action should the nurse take first?
A) Document the result as therapeutic and continue monitoring
B) Request an increase in the lithium dosage
C) Hold the next dose and notify the healthcare provider
D) Instruct the client to restrict fluid intake
Correct Answer: Hold the next dose and notify the healthcare provider
Rationale: The therapeutic range is 0.6–1.2 mEq/L; 1.8 mEq/L indicates toxicity. The nurse must hold
the medication and notify the provider immediately. Restricting fluids is contraindicated because
hydration promotes lithium excretion.
4. A nurse is assessing a client who has been taking haloperidol for several years. The client exhibits
involuntary tongue protrusion and lip smacking. Which condition should the nurse suspect?
A) Acute dystonia
B) Parkinsonian symptoms
C) Tardive dyskinesia
D) Akathisia
Correct Answer: Tardive dyskinesia
Rationale: Involuntary movements of the tongue and face are classic signs of tardive dyskinesia, a
potentially irreversible movement disorder from long-term antipsychotic use. Acute dystonia involves
muscle spasms, parkinsonism includes rigidity, and akathisia is restlessness.
5. A client diagnosed with borderline personality disorder praises one staff member while intensely
criticizing another. The nurse identifies this behavior as which defense mechanism?
A) Reaction formation
B) Splitting
C) Projection
, D) Rationalization
Correct Answer: Splitting
Rationale: Splitting involves viewing people or situations as all-good or all-bad, a common defense in
borderline personality disorder. Reaction formation converts unacceptable impulses into opposites,
projection attributes one's own feelings to others, and rationalization creates logical excuses.
6. A client experiencing a panic attack is hyperventilating and reports dizziness. Which nursing
intervention should be implemented first?
A) Administer a PRN benzodiazepine
B) Instruct the client to breathe slowly into a paper bag
C) Ask the client to identify the trigger for the anxiety
D) Escort the client to a quiet room
Correct Answer: Instruct the client to breathe slowly into a paper bag
Rationale: Hyperventilation causes hypocapnia, leading to dizziness and paresthesias. Rebreathing
carbon dioxide via a paper bag helps restore balance. Medication, trigger identification, and changing
location are secondary to immediate physiological stabilization.
7. A client with schizophrenia reports hearing voices commanding self-harm. Which nursing action has
the highest priority?
A) Ask the client to describe the voices in detail
B) Administer a PRN antipsychotic medication
C) Place the client on one-to-one suicide precautions
D) Reassure the client that the voices are not real
Correct Answer: Place the client on one-to-one suicide precautions
Nursing | Galen College | 26/27 Updated
(PDF)
1. A nurse is planning care for a client experiencing acute mania. Which intervention is most effective
for managing the client's excessive physical activity and ensuring safety?
A) Encouraging the client to participate in competitive sports
B) Allowing the client to wander freely to expend energy
C) Providing structured, low-stimulation activities with rest periods
D) Assigning the client to lead a high-energy exercise group
Correct Answer: Providing structured, low-stimulation activities with rest periods
Rationale: Structured activities with rest periods help channel energy constructively while preventing
exhaustion. Competitive sports may increase agitation, free wandering poses safety risks, and leading
a high-energy group is inappropriate for a manic client who lacks insight and judgment.
2. A client with major depressive disorder tells the nurse, "I am worthless and nothing I do matters."
Which nursing intervention is most therapeutic in response to this statement?
A) Reassuring the client that things will get better soon
B) Exploring the reasons behind the client's feelings of worthlessness
C) Encouraging the client to list personal strengths and accomplishments
D) Redirecting the conversation to a less negative topic
Correct Answer: Encouraging the client to list personal strengths and accomplishments
Rationale: Cognitive restructuring helps challenge negative self-perceptions by focusing on objective
evidence of worth. Reassurance may feel dismissive, exploring reasons may reinforce rumination, and
redirection avoids addressing the core issue.
,3. A client with bipolar disorder who is taking lithium has a serum level of 1.8 mEq/L drawn 12 hours
after the last dose. Which action should the nurse take first?
A) Document the result as therapeutic and continue monitoring
B) Request an increase in the lithium dosage
C) Hold the next dose and notify the healthcare provider
D) Instruct the client to restrict fluid intake
Correct Answer: Hold the next dose and notify the healthcare provider
Rationale: The therapeutic range is 0.6–1.2 mEq/L; 1.8 mEq/L indicates toxicity. The nurse must hold
the medication and notify the provider immediately. Restricting fluids is contraindicated because
hydration promotes lithium excretion.
4. A nurse is assessing a client who has been taking haloperidol for several years. The client exhibits
involuntary tongue protrusion and lip smacking. Which condition should the nurse suspect?
A) Acute dystonia
B) Parkinsonian symptoms
C) Tardive dyskinesia
D) Akathisia
Correct Answer: Tardive dyskinesia
Rationale: Involuntary movements of the tongue and face are classic signs of tardive dyskinesia, a
potentially irreversible movement disorder from long-term antipsychotic use. Acute dystonia involves
muscle spasms, parkinsonism includes rigidity, and akathisia is restlessness.
5. A client diagnosed with borderline personality disorder praises one staff member while intensely
criticizing another. The nurse identifies this behavior as which defense mechanism?
A) Reaction formation
B) Splitting
C) Projection
, D) Rationalization
Correct Answer: Splitting
Rationale: Splitting involves viewing people or situations as all-good or all-bad, a common defense in
borderline personality disorder. Reaction formation converts unacceptable impulses into opposites,
projection attributes one's own feelings to others, and rationalization creates logical excuses.
6. A client experiencing a panic attack is hyperventilating and reports dizziness. Which nursing
intervention should be implemented first?
A) Administer a PRN benzodiazepine
B) Instruct the client to breathe slowly into a paper bag
C) Ask the client to identify the trigger for the anxiety
D) Escort the client to a quiet room
Correct Answer: Instruct the client to breathe slowly into a paper bag
Rationale: Hyperventilation causes hypocapnia, leading to dizziness and paresthesias. Rebreathing
carbon dioxide via a paper bag helps restore balance. Medication, trigger identification, and changing
location are secondary to immediate physiological stabilization.
7. A client with schizophrenia reports hearing voices commanding self-harm. Which nursing action has
the highest priority?
A) Ask the client to describe the voices in detail
B) Administer a PRN antipsychotic medication
C) Place the client on one-to-one suicide precautions
D) Reassure the client that the voices are not real
Correct Answer: Place the client on one-to-one suicide precautions
