NSRG 126 Exam 3 V2 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 3) | Ivy Tech
1. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder, manic
phase. Which of the following nursing interventions should be the priority?
A. Encouraging participation in group therapy sessions
B. Encouraging the client to lead a community meeting
C. Assisting the client to identify triggers for mood swings
D. Providing a low-stimulus environment to prevent escalation
Correct Answer: D
Explanation: Safety and stabilization are the primary goals during an acute manic episode.
Reducing environmental stimuli helps to decrease the client’s distractibility and prevents
further behavioral escalation. Group activities and leadership roles are often too
overstimulating and inappropriate for a client in the acute manic phase.
2. A nurse is monitoring a client who has been taking Lithium carbonate for the past three
weeks. Which of the following findings should the nurse report to the provider as early signs
of lithium toxicity?
A. Increased appetite and weight gain
B. Constipation and dry mouth
,C. Slurred speech and muscle weakness
D. Nausea, vomiting, and diarrhea
E. Fine hand tremors and mild thirst
F. Course tremors and cardiac dysrhythmias
Correct Answer: E
Explanation: Fine hand tremors and mild thirst are common early signs that lithium levels
may be reaching a toxic range. While nausea and vomiting are also early signs, the
progression to slurred speech or course tremors indicates more severe toxicity. Frequent
monitoring of serum lithium levels is essential to prevent these complications.
3. A client diagnosed with Major Depressive Disorder (MDD) states, ‘Everything is useless. I
don’t think I can go on anymore.’ Which response by the nurse is the most therapeutic?
A. You have so much to live for; think of your family.
B. Are you feeling like you want to end your life?
C. It sounds like you are feeling very hopeless right now. Are you thinking of hurting
yourself?
D. Why do you feel that everything is useless?
Correct Answer: C
Explanation: This response combines the therapeutic technique of reflecting feelings with
a direct assessment of suicide risk. Direct questioning about suicidal ideation is necessary
, when a client expresses hopelessness. It allows the nurse to establish safety while
validating the client’s current emotional state.
4. A nurse is providing discharge teaching for a client prescribed Phenelzine, an MAOI. Which
food choice by the client indicates an understanding of the dietary restrictions?
A. Pepperoni pizza with extra cheese
B. Avocado toast with a side of soy sauce
C. Grilled chicken breast with steamed broccoli
D. A glass of red wine and aged cheddar
Correct Answer: C
Explanation: Clients taking MAOIs must follow a low-tyramine diet to avoid a
hypertensive crisis. Foods like aged cheeses, pepperoni, red wine, and fermented soy
products are high in tyramine and must be avoided. Freshly prepared meats and vegetables
like grilled chicken and broccoli are safe choices.
5. Which of the following behaviors is a hallmark characteristic of a client diagnosed with
Borderline Personality Disorder?
A. Social isolation and lack of interest in relationships
B. Arrogance and a grandiose sense of self-importance
C. Splitting, or viewing others as all good or all bad
D. Magical thinking and odd beliefs
Nursing | Actual Q&A with Rationale (NSRG126
Exam 3) | Ivy Tech
1. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder, manic
phase. Which of the following nursing interventions should be the priority?
A. Encouraging participation in group therapy sessions
B. Encouraging the client to lead a community meeting
C. Assisting the client to identify triggers for mood swings
D. Providing a low-stimulus environment to prevent escalation
Correct Answer: D
Explanation: Safety and stabilization are the primary goals during an acute manic episode.
Reducing environmental stimuli helps to decrease the client’s distractibility and prevents
further behavioral escalation. Group activities and leadership roles are often too
overstimulating and inappropriate for a client in the acute manic phase.
2. A nurse is monitoring a client who has been taking Lithium carbonate for the past three
weeks. Which of the following findings should the nurse report to the provider as early signs
of lithium toxicity?
A. Increased appetite and weight gain
B. Constipation and dry mouth
,C. Slurred speech and muscle weakness
D. Nausea, vomiting, and diarrhea
E. Fine hand tremors and mild thirst
F. Course tremors and cardiac dysrhythmias
Correct Answer: E
Explanation: Fine hand tremors and mild thirst are common early signs that lithium levels
may be reaching a toxic range. While nausea and vomiting are also early signs, the
progression to slurred speech or course tremors indicates more severe toxicity. Frequent
monitoring of serum lithium levels is essential to prevent these complications.
3. A client diagnosed with Major Depressive Disorder (MDD) states, ‘Everything is useless. I
don’t think I can go on anymore.’ Which response by the nurse is the most therapeutic?
A. You have so much to live for; think of your family.
B. Are you feeling like you want to end your life?
C. It sounds like you are feeling very hopeless right now. Are you thinking of hurting
yourself?
D. Why do you feel that everything is useless?
Correct Answer: C
Explanation: This response combines the therapeutic technique of reflecting feelings with
a direct assessment of suicide risk. Direct questioning about suicidal ideation is necessary
, when a client expresses hopelessness. It allows the nurse to establish safety while
validating the client’s current emotional state.
4. A nurse is providing discharge teaching for a client prescribed Phenelzine, an MAOI. Which
food choice by the client indicates an understanding of the dietary restrictions?
A. Pepperoni pizza with extra cheese
B. Avocado toast with a side of soy sauce
C. Grilled chicken breast with steamed broccoli
D. A glass of red wine and aged cheddar
Correct Answer: C
Explanation: Clients taking MAOIs must follow a low-tyramine diet to avoid a
hypertensive crisis. Foods like aged cheeses, pepperoni, red wine, and fermented soy
products are high in tyramine and must be avoided. Freshly prepared meats and vegetables
like grilled chicken and broccoli are safe choices.
5. Which of the following behaviors is a hallmark characteristic of a client diagnosed with
Borderline Personality Disorder?
A. Social isolation and lack of interest in relationships
B. Arrogance and a grandiose sense of self-importance
C. Splitting, or viewing others as all good or all bad
D. Magical thinking and odd beliefs
