NSRG 126 Exam 2 V1 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 2) | Ivy Tech
1. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which assessment finding should the nurse prioritize as the most significant risk factor for
suicide?
A. Poor hygiene and disheveled appearance
B. Psychomotor retardation and fatigue
C. A sudden improvement in mood and increased energy levels
D. Social withdrawal from family members
Correct Answer: C
Explanation: A sudden lift in mood often indicates that the client has finalized a suicide
plan and feels relief. This increased energy gives the client the physical means to carry out
the act. The nurse must monitor the client closely during this period of improved mood.
2. A nurse is providing teaching to a client starting Lithium Carbonate for Bipolar I Disorder.
Which of the following instructions should be included? (Select all that apply style, but
choose the most comprehensive single answer for this format)
A. Restrict sodium intake to prevent toxicity
B. Maintain consistent sodium and fluid intake
,C. Decrease fluid intake to 1 liter per day
D. Take the medication on an empty stomach
E. Stop taking the medication if a fine hand tremor develops
Correct Answer: B
Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
If sodium intake drops, the kidneys retain lithium, leading to toxicity. Maintaining a steady
fluid intake of 2-3 liters per day is also essential for renal health.
3. A client experiencing a panic attack is hyperventilating and states, ‘I feel like I am having a
heart attack and I am going to die.’ Which action should the nurse take first?
A. Administer an ordered PRN dose of Lorazepam
B. Teach the client a new relaxation technique
C. Stay with the client and use short, simple sentences
D. Ask the client to describe what triggered the attack
Correct Answer: C
Explanation: The safety of the client is the priority during a panic attack, and the nurse’s
presence provides a sense of security. During severe anxiety or panic, the client cannot
process complex information, so short sentences are necessary. Attempting to teach new
skills during a panic state is ineffective due to the client’s narrowed perceptual field.
, 4. Which clinical manifestation would the nurse expect to observe in a client experiencing the
‘Severe’ level of anxiety?
A. Increased alertness and problem-solving ability
B. Distorted perceptions and feelings of impending doom
C. Mild irritability and restlessness
D. Effective learning and enhanced concentration
Correct Answer: B
Explanation: Severe anxiety involves a significantly narrowed perceptual field where the
individual focuses on scattered details. Clients often experience physical symptoms like
hyperventilation and tachycardia along with intense emotional distress. Learning and
problem-solving are not possible at this level of anxiety.
5. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. Which meal
choice is most appropriate for this client?
A. Chicken wrap, apple slices, and a carton of milk
B. Spaghetti and meatballs with a side of garlic bread
C. Steak, baked potato, and salad
D. Soup and crackers in the dining room
Correct Answer: A
Nursing | Actual Q&A with Rationale (NSRG126
Exam 2) | Ivy Tech
1. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which assessment finding should the nurse prioritize as the most significant risk factor for
suicide?
A. Poor hygiene and disheveled appearance
B. Psychomotor retardation and fatigue
C. A sudden improvement in mood and increased energy levels
D. Social withdrawal from family members
Correct Answer: C
Explanation: A sudden lift in mood often indicates that the client has finalized a suicide
plan and feels relief. This increased energy gives the client the physical means to carry out
the act. The nurse must monitor the client closely during this period of improved mood.
2. A nurse is providing teaching to a client starting Lithium Carbonate for Bipolar I Disorder.
Which of the following instructions should be included? (Select all that apply style, but
choose the most comprehensive single answer for this format)
A. Restrict sodium intake to prevent toxicity
B. Maintain consistent sodium and fluid intake
,C. Decrease fluid intake to 1 liter per day
D. Take the medication on an empty stomach
E. Stop taking the medication if a fine hand tremor develops
Correct Answer: B
Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
If sodium intake drops, the kidneys retain lithium, leading to toxicity. Maintaining a steady
fluid intake of 2-3 liters per day is also essential for renal health.
3. A client experiencing a panic attack is hyperventilating and states, ‘I feel like I am having a
heart attack and I am going to die.’ Which action should the nurse take first?
A. Administer an ordered PRN dose of Lorazepam
B. Teach the client a new relaxation technique
C. Stay with the client and use short, simple sentences
D. Ask the client to describe what triggered the attack
Correct Answer: C
Explanation: The safety of the client is the priority during a panic attack, and the nurse’s
presence provides a sense of security. During severe anxiety or panic, the client cannot
process complex information, so short sentences are necessary. Attempting to teach new
skills during a panic state is ineffective due to the client’s narrowed perceptual field.
, 4. Which clinical manifestation would the nurse expect to observe in a client experiencing the
‘Severe’ level of anxiety?
A. Increased alertness and problem-solving ability
B. Distorted perceptions and feelings of impending doom
C. Mild irritability and restlessness
D. Effective learning and enhanced concentration
Correct Answer: B
Explanation: Severe anxiety involves a significantly narrowed perceptual field where the
individual focuses on scattered details. Clients often experience physical symptoms like
hyperventilation and tachycardia along with intense emotional distress. Learning and
problem-solving are not possible at this level of anxiety.
5. A nurse is caring for a client with Bipolar Disorder who is in the manic phase. Which meal
choice is most appropriate for this client?
A. Chicken wrap, apple slices, and a carton of milk
B. Spaghetti and meatballs with a side of garlic bread
C. Steak, baked potato, and salad
D. Soup and crackers in the dining room
Correct Answer: A
