NSRG 126 Exam 3 V3 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 3) | Ivy Tech
1. A nurse is caring for a client with Bipolar I disorder who is experiencing a manic episode.
Which finding is the nurse’s priority?
A. Flight of ideas
B. Pressured speech
C. Grandiosity
D. Lack of sleep
Correct Answer: D
Explanation: Safety and physiological stability are the highest priorities during an acute
manic episode. A lack of sleep can lead to physical exhaustion and even death if not
addressed promptly. The nurse must prioritize sleep and nutrition to ensure the client’s
basic physical needs are met before addressing psychological symptoms.
2. A client is prescribed Lithium Carbonate for mood stabilization. Which of the following
serum levels indicates a need for immediate intervention?
A. 0.8 mEq/L
B. 1.2 mEq/L
C. 1.8 mEq/L
,D. 0.6 mEq/L
Correct Answer: C
Explanation: Lithium has a narrow therapeutic range typically between 0.6 and 1.2 mEq/L
for maintenance. A level of 1.8 mEq/L indicates moderate to severe toxicity, which can lead
to seizures and cardiovascular collapse. The nurse must hold the medication and notify the
provider immediately while monitoring for symptoms like coarse tremors or ataxia.
3. A nurse is assessing a client for potential alcohol withdrawal. Which of the following are
early signs of withdrawal?
A. Fine tremors and tachycardia
B. Bradycardia and hypotension
C. Increased appetite and lethargy
D. Slurred speech and ataxia
Correct Answer: A
Explanation: Early signs of alcohol withdrawal usually begin within 6 to 8 hours after the
last drink. They include fine hand tremors, tachycardia, hypertension, and anxiety.
Recognizing these symptoms early allows for the initiation of the CIWA protocol to prevent
progression to delirium tremens.
4. A client with schizophrenia reports hearing voices telling them that the food is poisoned.
Which response by the nurse is therapeutic?
A. No one is poisoning your food, that’s just your illness.
, B. I will taste the food first to prove it is safe.
C. Why do you think the voices are telling you that?
D. I do not hear the voices, but I can see that you are frightened.
Correct Answer: D
Explanation: This response acknowledges the client’s feelings without validating the
delusion or arguing with the hallucination. Presenting reality in a non-confrontational way
is a core technique in psychiatric nursing. It builds trust while maintaining a focus on the
client’s emotional state rather than the false perception.
5. A nurse is educating a client on the side effects of Clozapine (Clozaril). What critical
monitoring parameter must the nurse emphasize?
A. Liver function tests
B. Serum potassium
C. Blood pressure
D. White blood cell (WBC) count
E. Renal function
F. Uric acid levels
Correct Answer: D
Explanation: Clozapine is associated with a high risk of agranulocytosis, a life-threatening
reduction in white blood cells. Clients must undergo weekly or bi-weekly blood monitoring
Nursing | Actual Q&A with Rationale (NSRG126
Exam 3) | Ivy Tech
1. A nurse is caring for a client with Bipolar I disorder who is experiencing a manic episode.
Which finding is the nurse’s priority?
A. Flight of ideas
B. Pressured speech
C. Grandiosity
D. Lack of sleep
Correct Answer: D
Explanation: Safety and physiological stability are the highest priorities during an acute
manic episode. A lack of sleep can lead to physical exhaustion and even death if not
addressed promptly. The nurse must prioritize sleep and nutrition to ensure the client’s
basic physical needs are met before addressing psychological symptoms.
2. A client is prescribed Lithium Carbonate for mood stabilization. Which of the following
serum levels indicates a need for immediate intervention?
A. 0.8 mEq/L
B. 1.2 mEq/L
C. 1.8 mEq/L
,D. 0.6 mEq/L
Correct Answer: C
Explanation: Lithium has a narrow therapeutic range typically between 0.6 and 1.2 mEq/L
for maintenance. A level of 1.8 mEq/L indicates moderate to severe toxicity, which can lead
to seizures and cardiovascular collapse. The nurse must hold the medication and notify the
provider immediately while monitoring for symptoms like coarse tremors or ataxia.
3. A nurse is assessing a client for potential alcohol withdrawal. Which of the following are
early signs of withdrawal?
A. Fine tremors and tachycardia
B. Bradycardia and hypotension
C. Increased appetite and lethargy
D. Slurred speech and ataxia
Correct Answer: A
Explanation: Early signs of alcohol withdrawal usually begin within 6 to 8 hours after the
last drink. They include fine hand tremors, tachycardia, hypertension, and anxiety.
Recognizing these symptoms early allows for the initiation of the CIWA protocol to prevent
progression to delirium tremens.
4. A client with schizophrenia reports hearing voices telling them that the food is poisoned.
Which response by the nurse is therapeutic?
A. No one is poisoning your food, that’s just your illness.
, B. I will taste the food first to prove it is safe.
C. Why do you think the voices are telling you that?
D. I do not hear the voices, but I can see that you are frightened.
Correct Answer: D
Explanation: This response acknowledges the client’s feelings without validating the
delusion or arguing with the hallucination. Presenting reality in a non-confrontational way
is a core technique in psychiatric nursing. It builds trust while maintaining a focus on the
client’s emotional state rather than the false perception.
5. A nurse is educating a client on the side effects of Clozapine (Clozaril). What critical
monitoring parameter must the nurse emphasize?
A. Liver function tests
B. Serum potassium
C. Blood pressure
D. White blood cell (WBC) count
E. Renal function
F. Uric acid levels
Correct Answer: D
Explanation: Clozapine is associated with a high risk of agranulocytosis, a life-threatening
reduction in white blood cells. Clients must undergo weekly or bi-weekly blood monitoring
