Nsg 3280 exam2 with questions and
verified answers in bold and
rationale updated 2026 graded A+
A nurse is assessing a patient with generalized anxiety disorder. The patient states, "I know the
doctor said my anxiety is from a chemical imbalance, so it's really not my fault I worry all the time."
This statement is an example of which defense mechanism?
A. Denial
B. Intellectualization
C. Rationalization
D. Projection
C. Rationalization
Rationale: Rationalization involves justifying illogical or unacceptable feelings, thoughts, or behaviors
with logical explanations. The patient is using the chemical imbalance as a reason to excuse
excessive worrying, thereby avoiding personal responsibility.
A patient with schizophrenia is experiencing an inability to initiate or persist in goal-directed
activities. The nurse documents this as:
A. Alogia
B. Avolition
C. Anhedonia
D. Affective flattening
B. Avolition
Rationale: Avolition is a negative symptom of schizophrenia characterized by a lack of motivation
and inability to initiate and continue purposeful activities. Alogia is poverty of speech, anhedonia is
inability to experience pleasure, and affective flattening is diminished emotional expression.
Which nursing intervention has the highest priority when caring for a patient experiencing a panic
attack?
,A. Teach deep breathing exercises
B. Explore possible triggers of the attack
C. Remain with the patient and provide reassurance
D. Administer a PRN anxiolytic immediately
C. Remain with the patient and provide reassurance
Rationale: During a panic attack, the patient’s ability to process information is impaired. The priority
is to ensure safety by staying with the patient, offering a calm presence, and providing simple,
reassuring statements. Breathing exercises can be introduced after the peak, and medication may be
given if ordered, but presence and reassurance are immediate.
A client taking lithium for bipolar disorder has a lithium level of 1.8 mEq/L. Which finding is most
concerning?
A. Fine hand tremor
B. Increased thirst
C. Nausea and vomiting
D. Ataxia and confusion
D. Ataxia and confusion
Rationale: A lithium level of 1.8 mEq/L indicates moderate to severe toxicity (therapeutic range 0.6-
1.2 mEq/L). Ataxia and confusion indicate neurotoxicity and require immediate medical intervention.
Nausea, tremor, and thirst may occur at therapeutic levels or early toxicity but are less emergent.
A patient with schizophrenia being treated with haloperidol develops torticollis and oculogyric crisis.
The nurse should anticipate administration of which PRN medication?
A. Lorazepam
B. Benztropine
C. Propranolol
D. Dantrolene
B. Benztropine
Rationale: The patient is experiencing acute dystonia, an extrapyramidal symptom caused by
dopamine blockade. Anticholinergic agents such as benztropine or diphenhydramine are used for
rapid relief. Lorazepam may be used for akathisia, propranolol for akathisia/tremor, and dantrolene
for neuroleptic malignant syndrome.
Which statement by a patient indicates the need for further teaching regarding phenelzine (Nardil)?
,A. "I cannot eat aged cheese or pepperoni."
B. "I should avoid over-the-counter cold medications."
C. "It may take a few weeks to feel the full effect."
D. "I can have a glass of red wine with dinner."
D. "I can have a glass of red wine with dinner."
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and tyramine-rich foods like red
wine can cause a hypertensive crisis. Aged cheese, pepperoni, and many cold medications
(containing decongestants) are also contraindicated. The patient must avoid all tyramine-containing
products.
A nurse is caring for a patient with major depressive disorder who has been taking fluoxetine for 3
days. The patient says, "This medication isn't working; I feel the same." The nurse's best response is:
A. "You may need a higher dose; I will call the provider."
B. "Let me talk to the doctor about switching your medication."
C. "It can take 2 to 4 weeks to notice improvement in mood."
D. "Fluoxetine usually works immediately; you should feel better soon."
C. "It can take 2 to 4 weeks to notice improvement in mood."
Rationale: Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine typically require 2–4 weeks,
and sometimes up to 6–8 weeks, to reach full therapeutic effect. Educating the patient about this
timeline encourages adherence.
A nurse is monitoring a patient receiving clozapine. Which laboratory result requires immediate
action?
A. Fasting blood glucose 110 mg/dL
B. White blood cell count 4,500/mm³
C. Absolute neutrophil count (ANC) 900/mm³
D. Hemoglobin 12 g/dL
C. Absolute neutrophil count (ANC) 900/mm³
Rationale: Clozapine carries a risk of agranulocytosis. An ANC less than 1,000/mm³ indicates severe
neutropenia and requires discontinuation of the drug and protective isolation. Slight hyperglycemia,
normal WBC, and normal hemoglobin are not urgent.
A patient on an inpatient psychiatric unit says, "The CIA is spying on me through the TV." What is the
nurse's best therapeutic response?
, A. "That's not true. Nobody is spying on you."
B. "Why do you think the CIA would be interested in you?"
C. "I understand that you believe the TV is watching you, but I do not see any evidence of that."
D. "You are safe here; no one will hurt you."
C. "I understand that you believe the TV is watching you, but I do not see any evidence of that."
Rationale: This response acknowledges the patient’s feeling without reinforcing the delusion, using
the technique of "voicing doubt." Directly challenging the delusion (A) is unhelpful. Asking "why" (B)
can be perceived as interrogating, and D does not address the delusion.
Which nursing action is a priority during the manic phase of bipolar disorder?
A. Encourage group therapy attendance
B. Provide high-calorie finger foods and fluids
C. Engage in competitive games to burn energy
D. Teach about the illness
B. Provide high-calorie finger foods and fluids
Rationale: Manic patients may have inadequate nutritional and fluid intake due to hyperactivity and
distractibility. Providing portable, high-calorie foods and fluids that can be consumed “on the go”
addresses physical needs and prevents dehydration and weight loss. Group activities, competition,
and teaching are overstimulating during acute mania.
A patient with alcohol use disorder is admitted for detoxification. The nurse initiates the CIWA-Ar
protocol. Which assessment finding indicates a need for PRN lorazepam?
A. Heart rate of 88 beats/min
B. Mild tremors and diaphoresis
C. Oriented to person, place, and time
D. Score of 16 on CIWA-Ar
D. Score of 16 on CIWA-Ar
Rationale: The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale scores symptom
severity. A score of 15 or higher indicates severe withdrawal risk and need for pharmacologic
intervention. Benzodiazepines like lorazepam are given based on objective symptom scores.
Which patient is at the highest risk for suicide?
A. A 68-year-old married male with onset of major depression 3 months ago
B. A 42-year-old female with melanoma and a strong family support system
verified answers in bold and
rationale updated 2026 graded A+
A nurse is assessing a patient with generalized anxiety disorder. The patient states, "I know the
doctor said my anxiety is from a chemical imbalance, so it's really not my fault I worry all the time."
This statement is an example of which defense mechanism?
A. Denial
B. Intellectualization
C. Rationalization
D. Projection
C. Rationalization
Rationale: Rationalization involves justifying illogical or unacceptable feelings, thoughts, or behaviors
with logical explanations. The patient is using the chemical imbalance as a reason to excuse
excessive worrying, thereby avoiding personal responsibility.
A patient with schizophrenia is experiencing an inability to initiate or persist in goal-directed
activities. The nurse documents this as:
A. Alogia
B. Avolition
C. Anhedonia
D. Affective flattening
B. Avolition
Rationale: Avolition is a negative symptom of schizophrenia characterized by a lack of motivation
and inability to initiate and continue purposeful activities. Alogia is poverty of speech, anhedonia is
inability to experience pleasure, and affective flattening is diminished emotional expression.
Which nursing intervention has the highest priority when caring for a patient experiencing a panic
attack?
,A. Teach deep breathing exercises
B. Explore possible triggers of the attack
C. Remain with the patient and provide reassurance
D. Administer a PRN anxiolytic immediately
C. Remain with the patient and provide reassurance
Rationale: During a panic attack, the patient’s ability to process information is impaired. The priority
is to ensure safety by staying with the patient, offering a calm presence, and providing simple,
reassuring statements. Breathing exercises can be introduced after the peak, and medication may be
given if ordered, but presence and reassurance are immediate.
A client taking lithium for bipolar disorder has a lithium level of 1.8 mEq/L. Which finding is most
concerning?
A. Fine hand tremor
B. Increased thirst
C. Nausea and vomiting
D. Ataxia and confusion
D. Ataxia and confusion
Rationale: A lithium level of 1.8 mEq/L indicates moderate to severe toxicity (therapeutic range 0.6-
1.2 mEq/L). Ataxia and confusion indicate neurotoxicity and require immediate medical intervention.
Nausea, tremor, and thirst may occur at therapeutic levels or early toxicity but are less emergent.
A patient with schizophrenia being treated with haloperidol develops torticollis and oculogyric crisis.
The nurse should anticipate administration of which PRN medication?
A. Lorazepam
B. Benztropine
C. Propranolol
D. Dantrolene
B. Benztropine
Rationale: The patient is experiencing acute dystonia, an extrapyramidal symptom caused by
dopamine blockade. Anticholinergic agents such as benztropine or diphenhydramine are used for
rapid relief. Lorazepam may be used for akathisia, propranolol for akathisia/tremor, and dantrolene
for neuroleptic malignant syndrome.
Which statement by a patient indicates the need for further teaching regarding phenelzine (Nardil)?
,A. "I cannot eat aged cheese or pepperoni."
B. "I should avoid over-the-counter cold medications."
C. "It may take a few weeks to feel the full effect."
D. "I can have a glass of red wine with dinner."
D. "I can have a glass of red wine with dinner."
Rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and tyramine-rich foods like red
wine can cause a hypertensive crisis. Aged cheese, pepperoni, and many cold medications
(containing decongestants) are also contraindicated. The patient must avoid all tyramine-containing
products.
A nurse is caring for a patient with major depressive disorder who has been taking fluoxetine for 3
days. The patient says, "This medication isn't working; I feel the same." The nurse's best response is:
A. "You may need a higher dose; I will call the provider."
B. "Let me talk to the doctor about switching your medication."
C. "It can take 2 to 4 weeks to notice improvement in mood."
D. "Fluoxetine usually works immediately; you should feel better soon."
C. "It can take 2 to 4 weeks to notice improvement in mood."
Rationale: Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine typically require 2–4 weeks,
and sometimes up to 6–8 weeks, to reach full therapeutic effect. Educating the patient about this
timeline encourages adherence.
A nurse is monitoring a patient receiving clozapine. Which laboratory result requires immediate
action?
A. Fasting blood glucose 110 mg/dL
B. White blood cell count 4,500/mm³
C. Absolute neutrophil count (ANC) 900/mm³
D. Hemoglobin 12 g/dL
C. Absolute neutrophil count (ANC) 900/mm³
Rationale: Clozapine carries a risk of agranulocytosis. An ANC less than 1,000/mm³ indicates severe
neutropenia and requires discontinuation of the drug and protective isolation. Slight hyperglycemia,
normal WBC, and normal hemoglobin are not urgent.
A patient on an inpatient psychiatric unit says, "The CIA is spying on me through the TV." What is the
nurse's best therapeutic response?
, A. "That's not true. Nobody is spying on you."
B. "Why do you think the CIA would be interested in you?"
C. "I understand that you believe the TV is watching you, but I do not see any evidence of that."
D. "You are safe here; no one will hurt you."
C. "I understand that you believe the TV is watching you, but I do not see any evidence of that."
Rationale: This response acknowledges the patient’s feeling without reinforcing the delusion, using
the technique of "voicing doubt." Directly challenging the delusion (A) is unhelpful. Asking "why" (B)
can be perceived as interrogating, and D does not address the delusion.
Which nursing action is a priority during the manic phase of bipolar disorder?
A. Encourage group therapy attendance
B. Provide high-calorie finger foods and fluids
C. Engage in competitive games to burn energy
D. Teach about the illness
B. Provide high-calorie finger foods and fluids
Rationale: Manic patients may have inadequate nutritional and fluid intake due to hyperactivity and
distractibility. Providing portable, high-calorie foods and fluids that can be consumed “on the go”
addresses physical needs and prevents dehydration and weight loss. Group activities, competition,
and teaching are overstimulating during acute mania.
A patient with alcohol use disorder is admitted for detoxification. The nurse initiates the CIWA-Ar
protocol. Which assessment finding indicates a need for PRN lorazepam?
A. Heart rate of 88 beats/min
B. Mild tremors and diaphoresis
C. Oriented to person, place, and time
D. Score of 16 on CIWA-Ar
D. Score of 16 on CIWA-Ar
Rationale: The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale scores symptom
severity. A score of 15 or higher indicates severe withdrawal risk and need for pharmacologic
intervention. Benzodiazepines like lorazepam are given based on objective symptom scores.
Which patient is at the highest risk for suicide?
A. A 68-year-old married male with onset of major depression 3 months ago
B. A 42-year-old female with melanoma and a strong family support system
