NUR 253 Exam 2 Actual Exam V2 | NUR 253 Mental Health Nursing
(NUR253 Exam 2) | Galen College of Nursing
1. A client is admitted to the emergency department with a suspected lithium toxicity. Which
of the following clinical findings should the nurse prioritize during the assessment?
A. Mild thirst and polyuria
B. Weight gain and mild nausea
C. Fine resting hand tremors
D. Coarse hand tremors and ataxia
Answer: D
Rationale: Coarse hand tremors and ataxia are significant indicators of advanced lithium
toxicity. While fine tremors are common side effects, coarse tremors suggest a serum level
above 1.5 mEq/L. The nurse must prioritize these neurological symptoms to prevent
progression to seizures or coma.
2. A nurse is caring for a client with schizophrenia who reports hearing voices saying ‘You are
a bad person.’ Which response by the nurse is therapeutic?
A. Let’s go to the dayroom to help you ignore the voices.
B. Why do you think the voices are saying that to you?
C. The voices are just a symptom of your illness and not real.
D. I don’t hear the voices, but I understand they are real to you.
Answer: D
Rationale: This response acknowledges the client’s experience without validating the
hallucination as reality. It provides a bridge between the client’s internal experience and
the nurse’s reality. Presenting reality in a non-confrontational manner is a core psychiatric
nursing intervention.
3. A client with Major Depressive Disorder is prescribed Phenelzine. Which food choice
indicates the client understands the dietary restrictions?
A. Grilled chicken breast and steamed broccoli
B. Pepperoni pizza and a side salad
C. Aged cheddar cheese and crackers
D. Red wine and sourdough bread
Answer: A
,Rationale: Phenelzine is an MAOI that requires a low-tyramine diet to prevent
hypertensive crisis. Grilled chicken and steamed broccoli are fresh, low-tyramine foods
suitable for this patient. Aged cheeses, cured meats, and fermented products like red wine
must be strictly avoided.
4. The nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS) after starting
Haloperidol. Which finding is considered a hallmark sign of this condition?
A. Extreme muscle rigidity and high fever
B. Hypotension and bradycardia
C. Tardive dyskinesia and lip smacking
D. Increased appetite and sedation
Answer: A
Rationale: Neuroleptic Malignant Syndrome is a life-threatening reaction to antipsychotics
characterized by severe lead-pipe rigidity and hyperpyrexia. Monitoring vital signs and
muscle tone is essential for early detection. Immediate discontinuation of the offending
agent and supportive care are required.
5. A client with Borderline Personality Disorder is observed ‘splitting’ staff members by
praising one nurse and criticizing another. What is the most appropriate nursing action?
A. Allow the client to choose which nurse they prefer to work with.
B. Explain to the client why their behavior is hurtful to the staff.
C. Maintain consistent communication among the treatment team.
D. Limit the client’s interactions to only one specific nurse per shift.
Answer: C
Rationale: Splitting is a defense mechanism where the client views people as all good or all
bad. Consistency among staff prevents the client from manipulating team members and
maintains therapeutic boundaries. Clear communication ensures that the care plan is
followed uniformly by all providers.
6. A nurse is teaching a client about a new prescription for Clozapine. Which laboratory value
must the nurse emphasize for weekly monitoring?
A. Serum potassium levels
B. Blood Urea Nitrogen (BUN)
C. Thyroid Stimulating Hormone (TSH)
D. White Blood Cell (WBC) count
Answer: D
, Rationale: Clozapine carries a high risk for agranulocytosis, a dangerous drop in white
blood cell counts. Patients must have their Absolute Neutrophil Count (ANC) monitored
weekly to ensure safety. This monitoring is mandated by the manufacturer and the FDA to
prevent life-threatening infections.
7. During an intake assessment, a client with Anorexia Nervosa displays peripheral edema
and a BMI of 15. What is the priority nursing diagnosis?
A. Imbalanced Nutrition: Less than Body Requirements
B. Disturbed Body Image
C. Risk for Injury related to low bone density
D. Ineffective Coping
E. Deficient Knowledge
Answer: A
Rationale: Physiological stability is the priority in patients with severe malnutrition and
low BMI. The presence of edema may indicate protein deficiency or fluid shifts related to
starvation. Addressing nutritional intake and electrolyte balance is critical to prevent
cardiac complications.
8. A client in the manic phase of Bipolar I Disorder is pacing the hallways and eating very
little. Which meal option should the nurse provide?
A. High-calorie, high-protein finger foods
B. A large bowl of hot soup and a sandwich
C. A scheduled three-course meal in the dining room
D. A fruit salad and low-fat yogurt cup
Answer: A
Rationale: Clients in a manic state often cannot sit still long enough to consume a full meal.
Finger foods allow the client to eat while moving, ensuring they receive necessary calories.
This intervention addresses nutritional needs without forcing the client into a restrictive
environment.
9. A client diagnosed with Generalized Anxiety Disorder (GAD) is experiencing a severe level
of anxiety. Which action should the nurse take first?
A. Teach the client deep breathing exercises.
B. Administer a PRN dose of Buspirone.
C. Provide a calm, quiet environment with low stimuli.
D. Ask the client to identify the cause of their anxiety.
(NUR253 Exam 2) | Galen College of Nursing
1. A client is admitted to the emergency department with a suspected lithium toxicity. Which
of the following clinical findings should the nurse prioritize during the assessment?
A. Mild thirst and polyuria
B. Weight gain and mild nausea
C. Fine resting hand tremors
D. Coarse hand tremors and ataxia
Answer: D
Rationale: Coarse hand tremors and ataxia are significant indicators of advanced lithium
toxicity. While fine tremors are common side effects, coarse tremors suggest a serum level
above 1.5 mEq/L. The nurse must prioritize these neurological symptoms to prevent
progression to seizures or coma.
2. A nurse is caring for a client with schizophrenia who reports hearing voices saying ‘You are
a bad person.’ Which response by the nurse is therapeutic?
A. Let’s go to the dayroom to help you ignore the voices.
B. Why do you think the voices are saying that to you?
C. The voices are just a symptom of your illness and not real.
D. I don’t hear the voices, but I understand they are real to you.
Answer: D
Rationale: This response acknowledges the client’s experience without validating the
hallucination as reality. It provides a bridge between the client’s internal experience and
the nurse’s reality. Presenting reality in a non-confrontational manner is a core psychiatric
nursing intervention.
3. A client with Major Depressive Disorder is prescribed Phenelzine. Which food choice
indicates the client understands the dietary restrictions?
A. Grilled chicken breast and steamed broccoli
B. Pepperoni pizza and a side salad
C. Aged cheddar cheese and crackers
D. Red wine and sourdough bread
Answer: A
,Rationale: Phenelzine is an MAOI that requires a low-tyramine diet to prevent
hypertensive crisis. Grilled chicken and steamed broccoli are fresh, low-tyramine foods
suitable for this patient. Aged cheeses, cured meats, and fermented products like red wine
must be strictly avoided.
4. The nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS) after starting
Haloperidol. Which finding is considered a hallmark sign of this condition?
A. Extreme muscle rigidity and high fever
B. Hypotension and bradycardia
C. Tardive dyskinesia and lip smacking
D. Increased appetite and sedation
Answer: A
Rationale: Neuroleptic Malignant Syndrome is a life-threatening reaction to antipsychotics
characterized by severe lead-pipe rigidity and hyperpyrexia. Monitoring vital signs and
muscle tone is essential for early detection. Immediate discontinuation of the offending
agent and supportive care are required.
5. A client with Borderline Personality Disorder is observed ‘splitting’ staff members by
praising one nurse and criticizing another. What is the most appropriate nursing action?
A. Allow the client to choose which nurse they prefer to work with.
B. Explain to the client why their behavior is hurtful to the staff.
C. Maintain consistent communication among the treatment team.
D. Limit the client’s interactions to only one specific nurse per shift.
Answer: C
Rationale: Splitting is a defense mechanism where the client views people as all good or all
bad. Consistency among staff prevents the client from manipulating team members and
maintains therapeutic boundaries. Clear communication ensures that the care plan is
followed uniformly by all providers.
6. A nurse is teaching a client about a new prescription for Clozapine. Which laboratory value
must the nurse emphasize for weekly monitoring?
A. Serum potassium levels
B. Blood Urea Nitrogen (BUN)
C. Thyroid Stimulating Hormone (TSH)
D. White Blood Cell (WBC) count
Answer: D
, Rationale: Clozapine carries a high risk for agranulocytosis, a dangerous drop in white
blood cell counts. Patients must have their Absolute Neutrophil Count (ANC) monitored
weekly to ensure safety. This monitoring is mandated by the manufacturer and the FDA to
prevent life-threatening infections.
7. During an intake assessment, a client with Anorexia Nervosa displays peripheral edema
and a BMI of 15. What is the priority nursing diagnosis?
A. Imbalanced Nutrition: Less than Body Requirements
B. Disturbed Body Image
C. Risk for Injury related to low bone density
D. Ineffective Coping
E. Deficient Knowledge
Answer: A
Rationale: Physiological stability is the priority in patients with severe malnutrition and
low BMI. The presence of edema may indicate protein deficiency or fluid shifts related to
starvation. Addressing nutritional intake and electrolyte balance is critical to prevent
cardiac complications.
8. A client in the manic phase of Bipolar I Disorder is pacing the hallways and eating very
little. Which meal option should the nurse provide?
A. High-calorie, high-protein finger foods
B. A large bowl of hot soup and a sandwich
C. A scheduled three-course meal in the dining room
D. A fruit salad and low-fat yogurt cup
Answer: A
Rationale: Clients in a manic state often cannot sit still long enough to consume a full meal.
Finger foods allow the client to eat while moving, ensuring they receive necessary calories.
This intervention addresses nutritional needs without forcing the client into a restrictive
environment.
9. A client diagnosed with Generalized Anxiety Disorder (GAD) is experiencing a severe level
of anxiety. Which action should the nurse take first?
A. Teach the client deep breathing exercises.
B. Administer a PRN dose of Buspirone.
C. Provide a calm, quiet environment with low stimuli.
D. Ask the client to identify the cause of their anxiety.
