NUR 253 EXAM 3 MENTAL HEALTH
() QUESTIONS & VERIFIED
ANSWERS (A+ GUARANTEE) | GALEN
COLLEGE OF NURSING
1. A client diagnosed with schizophrenia is experiencing command hallucinations to harm
others. Which nursing action takes priority?
A. Place the client in physical restraints
B. Determine the content of the hallucinations
C. Administer an intramuscular antipsychotic
D. Instruct the client to ignore the voices
Answer: B
Conceptual Explanation: The first priority in command hallucinations is to assess the
content to determine the level of risk to others or the client.
2. A client is prescribed Clozapine. Which laboratory value requires immediate notification of
the healthcare provider?
A. WBC count of 2,500/mm³
B. Platelet count of 150,000/mm³
,C. Hemoglobin of 12 g/dL
D. Serum sodium of 135 mEq/L
Answer: A
Conceptual Explanation: Clozapine carries a risk for agranulocytosis. A WBC count below
3,000/mm³ or ANC below 1,500/mm³ requires stopping the medication and notifying the
provider.
3. A client taking a Monoamine Oxidase Inhibitor (MAOI) reports a severe headache and neck
stiffness. What is the nurse’s first action?
A. Administer acetaminophen for the headache
B. Check the client’s blood pressure
C. Perform a complete neurological assessment
D. Assess for signs of serotonin syndrome
Answer: B
Conceptual Explanation: These are classic signs of a hypertensive crisis, a medical
emergency associated with MAOIs and tyramine-rich foods.
4. Which assessment finding best differentiates delirium from dementia?
A. Loss of memory for recent events
B. Rapid onset of symptoms and fluctuating level of consciousness
C. Disorientation to time and place
, D. Confabulation to fill in memory gaps
Answer: B
Conceptual Explanation: Delirium is characterized by an acute, rapid onset and a
fluctuating level of consciousness, whereas dementia is progressive and stable.
5. A client with Borderline Personality Disorder uses ‘splitting’ when interacting with staff.
How should the nurse manager intervene?
A. Ensure consistent communication and limits among all staff
B. Allow the client to choose their assigned nurse
C. Confront the client about their manipulative behavior
D. Restrict the client’s interaction with other patients
Answer: A
Conceptual Explanation: Consistency among the treatment team is vital to prevent
splitting, where the client views staff as all good or all bad.
6. According to the ‘Duty to Warn’ (Tarasoff) principle, what is the nurse’s legal obligation?
A. Notify the authorities and the intended victim if a client makes a specific threat
B. Keep all client statements confidential regardless of the content
C. Obtain informed consent before sharing information with the family
D. Place the client in seclusion if they express anger toward others
() QUESTIONS & VERIFIED
ANSWERS (A+ GUARANTEE) | GALEN
COLLEGE OF NURSING
1. A client diagnosed with schizophrenia is experiencing command hallucinations to harm
others. Which nursing action takes priority?
A. Place the client in physical restraints
B. Determine the content of the hallucinations
C. Administer an intramuscular antipsychotic
D. Instruct the client to ignore the voices
Answer: B
Conceptual Explanation: The first priority in command hallucinations is to assess the
content to determine the level of risk to others or the client.
2. A client is prescribed Clozapine. Which laboratory value requires immediate notification of
the healthcare provider?
A. WBC count of 2,500/mm³
B. Platelet count of 150,000/mm³
,C. Hemoglobin of 12 g/dL
D. Serum sodium of 135 mEq/L
Answer: A
Conceptual Explanation: Clozapine carries a risk for agranulocytosis. A WBC count below
3,000/mm³ or ANC below 1,500/mm³ requires stopping the medication and notifying the
provider.
3. A client taking a Monoamine Oxidase Inhibitor (MAOI) reports a severe headache and neck
stiffness. What is the nurse’s first action?
A. Administer acetaminophen for the headache
B. Check the client’s blood pressure
C. Perform a complete neurological assessment
D. Assess for signs of serotonin syndrome
Answer: B
Conceptual Explanation: These are classic signs of a hypertensive crisis, a medical
emergency associated with MAOIs and tyramine-rich foods.
4. Which assessment finding best differentiates delirium from dementia?
A. Loss of memory for recent events
B. Rapid onset of symptoms and fluctuating level of consciousness
C. Disorientation to time and place
, D. Confabulation to fill in memory gaps
Answer: B
Conceptual Explanation: Delirium is characterized by an acute, rapid onset and a
fluctuating level of consciousness, whereas dementia is progressive and stable.
5. A client with Borderline Personality Disorder uses ‘splitting’ when interacting with staff.
How should the nurse manager intervene?
A. Ensure consistent communication and limits among all staff
B. Allow the client to choose their assigned nurse
C. Confront the client about their manipulative behavior
D. Restrict the client’s interaction with other patients
Answer: A
Conceptual Explanation: Consistency among the treatment team is vital to prevent
splitting, where the client views staff as all good or all bad.
6. According to the ‘Duty to Warn’ (Tarasoff) principle, what is the nurse’s legal obligation?
A. Notify the authorities and the intended victim if a client makes a specific threat
B. Keep all client statements confidential regardless of the content
C. Obtain informed consent before sharing information with the family
D. Place the client in seclusion if they express anger toward others
