NUR 253 Exam 1 Actual Exam V1 | NUR 253 Mental Health Nursing
(NUR253 Exam 1) | Galen College of Nursing
1. A nurse is performing a mental status examination (MSE) on a newly admitted client.
Which of the following components should the nurse evaluate when assessing the client’s
‘Affect’?
A. The client’s internal emotional state as reported by the client.
B. The client’s ability to perform abstract reasoning.
C. The client’s objective expression of their emotional state.
D. The client’s orientation to time, place, and person.
Answer: C
Rationale: Affect is the objective, observable expression of a client’s emotional state, such
as facial expressions or hand gestures. In contrast, mood is the subjective emotional state
reported by the client. This analysis involves distinguishing between outward signs and
internal feelings during a psychiatric assessment.
2. A client is hospitalized for severe depression and expresses thoughts of hopelessness.
Which ethical principle is the nurse upholding when they prioritize staying with the client
during a crisis?
A. Autonomy
B. Veracity
C. Beneficence
D. Justice
Answer: C
Rationale: Beneficence refers to the duty to act in ways that benefit others and promote
the good of the client. By staying with a client in crisis to ensure safety and emotional
support, the nurse is actively promoting the client’s well-being. This is a foundational
concept in mental health nursing ethics.
3. Which statement by the nurse demonstrates the therapeutic communication technique of
‘restating’?
A. Are you saying that you feel overwhelmed by your current workload?
B. I noticed you were clenching your fists while talking about your father.
C. Why do you feel that your family does not support you?
D. Tell me more about your experience in the military.
,Answer: A
Rationale: Restating involves repeating the main idea expressed by the client to verify that
the nurse has understood. It encourages the client to continue and provides an opportunity
for clarification. This helps build a therapeutic alliance and ensures accurate assessment
data.
4. A client with an obsessive-compulsive disorder (OCD) is late for breakfast because they are
repeating a hand-washing ritual. What is the most appropriate nursing intervention?
A. Allow the client enough time at the start of the shift to complete the ritual.
B. Interrupt the ritual and demand the client go to the dining hall immediately.
C. Explain to the client that their behavior is irrational and unnecessary.
D. Lock the bathroom door to prevent the client from accessing the sink.
Answer: A
Rationale: In the early stages of treatment for OCD, the nurse should allow the client to
perform the ritual to prevent overwhelming anxiety. Abruptly stopping a ritual can cause a
panic-level response. The long-term goal is to decrease the time spent on rituals, but
immediate safety and anxiety management are priorities.
5. Which legal concept describes the nurse’s obligation to warn a third party if a client
threatens to harm them?
A. Habeas Corpus
B. Duty to Warn
C. Informed Consent
D. Right to Refuse Treatment
Answer: B
Rationale: The Duty to Warn (based on the Tarasoff ruling) requires mental health
professionals to breach confidentiality if a client poses a specific threat to an identifiable
person. This is a critical legal and ethical exception to the client’s right to privacy. The
nurse must report such threats to the treatment team and potentially the authorities.
6. A nurse is caring for a client who is experiencing moderate anxiety. Which physiological
manifestation should the nurse expect to observe?
A. Dilated pupils and cool, clammy skin.
B. Total loss of focus and inability to communicate.
C. Increased heart rate and muscle tension.
D. Deep sleep and bradycardia.
, Answer: C
Rationale: Moderate anxiety triggers the sympathetic nervous system, leading to increased
heart rate, perspiration, and muscle tension. The client’s perceptual field narrows, but they
can still follow directions. Understanding the levels of anxiety allows the nurse to tailor
interventions appropriately.
7. An older adult client is admitted to the psychiatric unit. According to Erikson’s stages of
psychosocial development, which developmental task is most relevant for this client?
A. Generativity vs. Stagnation
B. Identity vs. Role Confusion
C. Intimacy vs. Isolation
D. Ego Integrity vs. Despair
Answer: D
Rationale: Erikson’s stage for older adulthood (65+ years) is Ego Integrity vs. Despair,
where the individual reflects on their life. Success leads to a sense of wisdom and
fulfillment, while failure leads to regret. Nurses must assess for signs of despair, which can
manifest as depression in elderly clients.
8. A client tells the nurse, ‘I don’t think I should take this medication because I feel fine now.’
Which response by the nurse is most therapeutic?
A. Tell me more about your thoughts regarding stopping the medication.
B. Why would you want to stop something that is working?
C. You have to take it; otherwise, you will get sick again.
D. I will have to tell the doctor that you are being non-compliant.
Answer: A
Rationale: Using an open-ended statement like ‘Tell me more’ allows the client to express
their concerns and provides the nurse with more information for assessment. It avoids
being judgmental or defensive. This approach respects the client’s autonomy while
facilitating a therapeutic dialogue.
9. A nurse is caring for a client who uses ‘reaction formation’ as a defense mechanism. Which
behavior is an example of this?
A. A man who is angry at his boss comes home and yells at his wife.
B. An individual forgets a traumatic event that happened in childhood.
C. A person who dislikes their neighbor tells everyone how wonderful that neighbor is.
D. A student blames their poor grade on the teacher’s ‘confusing’ questions.
(NUR253 Exam 1) | Galen College of Nursing
1. A nurse is performing a mental status examination (MSE) on a newly admitted client.
Which of the following components should the nurse evaluate when assessing the client’s
‘Affect’?
A. The client’s internal emotional state as reported by the client.
B. The client’s ability to perform abstract reasoning.
C. The client’s objective expression of their emotional state.
D. The client’s orientation to time, place, and person.
Answer: C
Rationale: Affect is the objective, observable expression of a client’s emotional state, such
as facial expressions or hand gestures. In contrast, mood is the subjective emotional state
reported by the client. This analysis involves distinguishing between outward signs and
internal feelings during a psychiatric assessment.
2. A client is hospitalized for severe depression and expresses thoughts of hopelessness.
Which ethical principle is the nurse upholding when they prioritize staying with the client
during a crisis?
A. Autonomy
B. Veracity
C. Beneficence
D. Justice
Answer: C
Rationale: Beneficence refers to the duty to act in ways that benefit others and promote
the good of the client. By staying with a client in crisis to ensure safety and emotional
support, the nurse is actively promoting the client’s well-being. This is a foundational
concept in mental health nursing ethics.
3. Which statement by the nurse demonstrates the therapeutic communication technique of
‘restating’?
A. Are you saying that you feel overwhelmed by your current workload?
B. I noticed you were clenching your fists while talking about your father.
C. Why do you feel that your family does not support you?
D. Tell me more about your experience in the military.
,Answer: A
Rationale: Restating involves repeating the main idea expressed by the client to verify that
the nurse has understood. It encourages the client to continue and provides an opportunity
for clarification. This helps build a therapeutic alliance and ensures accurate assessment
data.
4. A client with an obsessive-compulsive disorder (OCD) is late for breakfast because they are
repeating a hand-washing ritual. What is the most appropriate nursing intervention?
A. Allow the client enough time at the start of the shift to complete the ritual.
B. Interrupt the ritual and demand the client go to the dining hall immediately.
C. Explain to the client that their behavior is irrational and unnecessary.
D. Lock the bathroom door to prevent the client from accessing the sink.
Answer: A
Rationale: In the early stages of treatment for OCD, the nurse should allow the client to
perform the ritual to prevent overwhelming anxiety. Abruptly stopping a ritual can cause a
panic-level response. The long-term goal is to decrease the time spent on rituals, but
immediate safety and anxiety management are priorities.
5. Which legal concept describes the nurse’s obligation to warn a third party if a client
threatens to harm them?
A. Habeas Corpus
B. Duty to Warn
C. Informed Consent
D. Right to Refuse Treatment
Answer: B
Rationale: The Duty to Warn (based on the Tarasoff ruling) requires mental health
professionals to breach confidentiality if a client poses a specific threat to an identifiable
person. This is a critical legal and ethical exception to the client’s right to privacy. The
nurse must report such threats to the treatment team and potentially the authorities.
6. A nurse is caring for a client who is experiencing moderate anxiety. Which physiological
manifestation should the nurse expect to observe?
A. Dilated pupils and cool, clammy skin.
B. Total loss of focus and inability to communicate.
C. Increased heart rate and muscle tension.
D. Deep sleep and bradycardia.
, Answer: C
Rationale: Moderate anxiety triggers the sympathetic nervous system, leading to increased
heart rate, perspiration, and muscle tension. The client’s perceptual field narrows, but they
can still follow directions. Understanding the levels of anxiety allows the nurse to tailor
interventions appropriately.
7. An older adult client is admitted to the psychiatric unit. According to Erikson’s stages of
psychosocial development, which developmental task is most relevant for this client?
A. Generativity vs. Stagnation
B. Identity vs. Role Confusion
C. Intimacy vs. Isolation
D. Ego Integrity vs. Despair
Answer: D
Rationale: Erikson’s stage for older adulthood (65+ years) is Ego Integrity vs. Despair,
where the individual reflects on their life. Success leads to a sense of wisdom and
fulfillment, while failure leads to regret. Nurses must assess for signs of despair, which can
manifest as depression in elderly clients.
8. A client tells the nurse, ‘I don’t think I should take this medication because I feel fine now.’
Which response by the nurse is most therapeutic?
A. Tell me more about your thoughts regarding stopping the medication.
B. Why would you want to stop something that is working?
C. You have to take it; otherwise, you will get sick again.
D. I will have to tell the doctor that you are being non-compliant.
Answer: A
Rationale: Using an open-ended statement like ‘Tell me more’ allows the client to express
their concerns and provides the nurse with more information for assessment. It avoids
being judgmental or defensive. This approach respects the client’s autonomy while
facilitating a therapeutic dialogue.
9. A nurse is caring for a client who uses ‘reaction formation’ as a defense mechanism. Which
behavior is an example of this?
A. A man who is angry at his boss comes home and yells at his wife.
B. An individual forgets a traumatic event that happened in childhood.
C. A person who dislikes their neighbor tells everyone how wonderful that neighbor is.
D. A student blames their poor grade on the teacher’s ‘confusing’ questions.
