NSRG 126 Exam 2 V2 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 2) | Ivy Tech
1. A nurse is caring for a client experiencing a severe panic attack. Which of the following
actions should the nurse take first?
A. Stay with the client and use short, simple sentences.
B. Ask the client to explain the trigger for their anxiety.
C. Encourage the client to practice deep breathing in a crowded room.
D. Administer a dose of an SSRI medication immediately.
Correct Answer: A
Explanation: During a severe panic attack, the nurse’s priority is to remain with the
patient to ensure safety and provide a sense of security. The nurse should use clear,
concise, and calm communication because the client’s ability to process information is
severely limited. Reducing environmental stimuli is also vital to help the client regain
emotional control during the episode.
2. A client with Bipolar I Disorder is prescribed lithium carbonate for maintenance therapy.
Which of the following serum lithium levels indicates the patient is within the therapeutic
range?
A. 0.2 mEq/L
B. 0.9 mEq/L
,C. 1.6 mEq/L
D. 2.1 mEq/L
Correct Answer: B
Explanation: The therapeutic serum range for lithium during maintenance therapy is
typically 0.6 to 1.2 mEq/L. Levels below this range are generally ineffective for mood
stabilization, while levels above 1.5 mEq/L can lead to toxicity. The nurse must monitor
blood levels regularly and educate the patient on the importance of maintaining consistent
salt and fluid intake.
3. A nurse is assessing a client with Antisocial Personality Disorder. Which of the following
behaviors should the nurse expect to observe?
A. Extreme sensitivity to rejection and social withdrawal.
B. Excessive emotionality and attention-seeking behavior.
C. Lack of remorse for actions and manipulation of others.
D. Intense fear of abandonment and self-harming tendencies.
Correct Answer: C
Explanation: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others and a significant lack of remorse. These individuals often
engage in deceitful and manipulative behaviors for personal gain or pleasure. The nurse
must maintain clear boundaries and consistent consequences when managing care for
these patients.
,4. A client diagnosed with Anorexia Nervosa is being admitted to an inpatient unit. Which of
the following physical findings is a priority for the nurse to address?
A. Bradycardia and an electrolyte imbalance.
B. Lanugo on the back and extremities.
C. Amenorrhea for the past six months.
D. Yellowish skin tone due to hypercarotenemia.
Correct Answer: A
Explanation: While all the listed findings are common in anorexia, cardiovascular
instability like bradycardia and electrolyte imbalances are life-threatening. These physical
manifestations indicate the body’s compensatory mechanisms are failing due to severe
malnutrition. Initial treatment focuses on medical stabilization and monitoring for
refeeding syndrome during nutritional rehabilitation.
5. A nurse is providing teaching to a client with a new prescription for Alprazolam. Which of
the following instructions should the nurse include?
A. ‘This medication can be stopped abruptly once you feel better.’
B. ‘Avoid driving or operating heavy machinery until you know how this affects you.’
C. ‘You should drink a glass of wine to help you relax while taking this.’
D. ‘This medication is intended for long-term management of chronic anxiety.’
Correct Answer: B
, Explanation: Alprazolam is a benzodiazepine that causes central nervous system
depression, leading to drowsiness and impaired coordination. Patients must be warned
about safety risks associated with activities requiring alertness while taking this
medication. Additionally, it carries a high risk for dependence and should never be
discontinued suddenly due to the risk of withdrawal seizures.
6. A client who has been taking Sertraline for two weeks reports feeling ‘restless’ and is
experiencing muscle twitches and a high fever. Which condition should the nurse suspect?
A. Neuroleptic Malignant Syndrome
B. Tardive Dyskinesia
C. Anticholinergic Toxicity
D. Serotonin Syndrome
Correct Answer: D
Explanation: Serotonin Syndrome is a potentially life-threatening condition caused by an
excess of serotonin, often occurring shortly after starting or increasing the dose of an SSRI.
Clinical manifestations include mental status changes, autonomic hyperactivity, and
neuromuscular abnormalities like tremors or clonus. Immediate discontinuation of the
medication and supportive care are necessary to prevent further complications.
Nursing | Actual Q&A with Rationale (NSRG126
Exam 2) | Ivy Tech
1. A nurse is caring for a client experiencing a severe panic attack. Which of the following
actions should the nurse take first?
A. Stay with the client and use short, simple sentences.
B. Ask the client to explain the trigger for their anxiety.
C. Encourage the client to practice deep breathing in a crowded room.
D. Administer a dose of an SSRI medication immediately.
Correct Answer: A
Explanation: During a severe panic attack, the nurse’s priority is to remain with the
patient to ensure safety and provide a sense of security. The nurse should use clear,
concise, and calm communication because the client’s ability to process information is
severely limited. Reducing environmental stimuli is also vital to help the client regain
emotional control during the episode.
2. A client with Bipolar I Disorder is prescribed lithium carbonate for maintenance therapy.
Which of the following serum lithium levels indicates the patient is within the therapeutic
range?
A. 0.2 mEq/L
B. 0.9 mEq/L
,C. 1.6 mEq/L
D. 2.1 mEq/L
Correct Answer: B
Explanation: The therapeutic serum range for lithium during maintenance therapy is
typically 0.6 to 1.2 mEq/L. Levels below this range are generally ineffective for mood
stabilization, while levels above 1.5 mEq/L can lead to toxicity. The nurse must monitor
blood levels regularly and educate the patient on the importance of maintaining consistent
salt and fluid intake.
3. A nurse is assessing a client with Antisocial Personality Disorder. Which of the following
behaviors should the nurse expect to observe?
A. Extreme sensitivity to rejection and social withdrawal.
B. Excessive emotionality and attention-seeking behavior.
C. Lack of remorse for actions and manipulation of others.
D. Intense fear of abandonment and self-harming tendencies.
Correct Answer: C
Explanation: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others and a significant lack of remorse. These individuals often
engage in deceitful and manipulative behaviors for personal gain or pleasure. The nurse
must maintain clear boundaries and consistent consequences when managing care for
these patients.
,4. A client diagnosed with Anorexia Nervosa is being admitted to an inpatient unit. Which of
the following physical findings is a priority for the nurse to address?
A. Bradycardia and an electrolyte imbalance.
B. Lanugo on the back and extremities.
C. Amenorrhea for the past six months.
D. Yellowish skin tone due to hypercarotenemia.
Correct Answer: A
Explanation: While all the listed findings are common in anorexia, cardiovascular
instability like bradycardia and electrolyte imbalances are life-threatening. These physical
manifestations indicate the body’s compensatory mechanisms are failing due to severe
malnutrition. Initial treatment focuses on medical stabilization and monitoring for
refeeding syndrome during nutritional rehabilitation.
5. A nurse is providing teaching to a client with a new prescription for Alprazolam. Which of
the following instructions should the nurse include?
A. ‘This medication can be stopped abruptly once you feel better.’
B. ‘Avoid driving or operating heavy machinery until you know how this affects you.’
C. ‘You should drink a glass of wine to help you relax while taking this.’
D. ‘This medication is intended for long-term management of chronic anxiety.’
Correct Answer: B
, Explanation: Alprazolam is a benzodiazepine that causes central nervous system
depression, leading to drowsiness and impaired coordination. Patients must be warned
about safety risks associated with activities requiring alertness while taking this
medication. Additionally, it carries a high risk for dependence and should never be
discontinued suddenly due to the risk of withdrawal seizures.
6. A client who has been taking Sertraline for two weeks reports feeling ‘restless’ and is
experiencing muscle twitches and a high fever. Which condition should the nurse suspect?
A. Neuroleptic Malignant Syndrome
B. Tardive Dyskinesia
C. Anticholinergic Toxicity
D. Serotonin Syndrome
Correct Answer: D
Explanation: Serotonin Syndrome is a potentially life-threatening condition caused by an
excess of serotonin, often occurring shortly after starting or increasing the dose of an SSRI.
Clinical manifestations include mental status changes, autonomic hyperactivity, and
neuromuscular abnormalities like tremors or clonus. Immediate discontinuation of the
medication and supportive care are necessary to prevent further complications.
