NSRG 126 Exam 2 V3 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 2) | Ivy Tech
1. A nurse is assessing a client with Major Depressive Disorder who reports a total loss of
interest in activities they previously enjoyed. Which term should the nurse use to document
this finding?
A. Alogia
B. Anhedonia
C. Anosognosia
D. Akathisia
Correct Answer: B
Explanation: Anhedonia is defined as the inability to experience pleasure from activities
that were once found enjoyable. It is a core clinical feature of depression and must be
accurately documented in the psychiatric assessment. The other terms refer to poverty of
speech, lack of insight into illness, and motor restlessness respectively.
2. A client is being treated with Lithium carbonate for Bipolar I Disorder. The nurse monitors
for signs of toxicity. Which of the following symptoms should the nurse identify as indicative
of advanced lithium toxicity?
A. Fine hand tremors and mild thirst
B. Mild nausea and polyuria
,C. Metallic taste in the mouth
D. Increased appetite and weight gain
E. Blurred vision, ataxia, and persistent gastrointestinal upset
F. Constipation and dry skin
Correct Answer: E
Explanation: Advanced lithium toxicity occurs at levels above 1.5 mEq/L and manifests
with significant neurological and systemic symptoms such as ataxia and blurred vision.
Mild tremors and nausea are often expected side effects at therapeutic levels rather than
signs of toxicity. The nurse must prioritize immediate intervention, including holding the
dose and obtaining a serum level, when these advanced signs are observed.
3. A nurse is providing education to a client prescribed a Selective Serotonin Reuptake
Inhibitor (SSRI). Which instruction is most critical for the nurse to include to ensure client
safety?
A. Do not stop the medication abruptly to avoid discontinuation syndrome.
B. Take the medication with a high-fat meal to increase absorption.
C. Expect the full therapeutic effect to occur within 24 to 48 hours.
D. Restrict fluid intake to prevent hyponatremia while on this drug.
Correct Answer: A
,Explanation: Abrupt cessation of SSRIs can lead to a cluster of withdrawal-like symptoms
known as discontinuation syndrome, which includes dizziness and irritability. Clients
should be educated on the importance of tapering the dose under medical supervision.
Furthermore, therapeutic effects typically take 2 to 4 weeks to manifest, which is a key
point for managing patient expectations.
4. A client diagnosed with Bipolar Disorder is in the acute manic phase. Which meal choice is
most appropriate for this client?
A. A large steak with baked potato and a side salad
B. Spaghetti and meatballs with a glass of red wine
C. A bowl of hot vegetable soup with crackers
D. Chicken wraps, an apple, and a carton of milk
Correct Answer: D
Explanation: Clients in an acute manic state often have high energy levels and a short
attention span, making it difficult for them to sit down for a traditional meal. ‘Finger foods’
that are high in protein and calories allow the client to eat while moving around the milieu.
This intervention helps maintain nutritional status and prevents physical exhaustion
during manic episodes.
5. A nurse is assessing a client for Post-Traumatic Stress Disorder (PTSD). Which findings are
characteristic of this disorder? (Select all that apply)
A. Flashbacks and intrusive thoughts of the traumatic event
, B. Hypervigilance and an exaggerated startle response
C. Excessive sleeping and increased appetite
D. Avoidance of places or people associated with the trauma
E. A sudden urge to clean and organize the environment
F. Increased social engagement and talkativeness
Correct Answer: A, B, D
Explanation: PTSD is characterized by three main clusters of symptoms: re-experiencing
(flashbacks), arousal (hypervigilance), and avoidance. These symptoms must persist for
more than one month and cause significant distress or functional impairment. Nursing care
focuses on establishing trust and helping the client develop coping mechanisms for these
distressing symptoms.
6. The nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who performs a
handwashing ritual for 15 minutes every hour. What is the most appropriate initial nursing
intervention?
A. Physically prevent the client from using the sink during ritual times.
B. Allow the client enough time to perform the ritual initially.
C. Explain to the client that their hands are already clean and germs are gone.
D. Provide the client with a detailed schedule of group therapies to attend.
Correct Answer: B
Nursing | Actual Q&A with Rationale (NSRG126
Exam 2) | Ivy Tech
1. A nurse is assessing a client with Major Depressive Disorder who reports a total loss of
interest in activities they previously enjoyed. Which term should the nurse use to document
this finding?
A. Alogia
B. Anhedonia
C. Anosognosia
D. Akathisia
Correct Answer: B
Explanation: Anhedonia is defined as the inability to experience pleasure from activities
that were once found enjoyable. It is a core clinical feature of depression and must be
accurately documented in the psychiatric assessment. The other terms refer to poverty of
speech, lack of insight into illness, and motor restlessness respectively.
2. A client is being treated with Lithium carbonate for Bipolar I Disorder. The nurse monitors
for signs of toxicity. Which of the following symptoms should the nurse identify as indicative
of advanced lithium toxicity?
A. Fine hand tremors and mild thirst
B. Mild nausea and polyuria
,C. Metallic taste in the mouth
D. Increased appetite and weight gain
E. Blurred vision, ataxia, and persistent gastrointestinal upset
F. Constipation and dry skin
Correct Answer: E
Explanation: Advanced lithium toxicity occurs at levels above 1.5 mEq/L and manifests
with significant neurological and systemic symptoms such as ataxia and blurred vision.
Mild tremors and nausea are often expected side effects at therapeutic levels rather than
signs of toxicity. The nurse must prioritize immediate intervention, including holding the
dose and obtaining a serum level, when these advanced signs are observed.
3. A nurse is providing education to a client prescribed a Selective Serotonin Reuptake
Inhibitor (SSRI). Which instruction is most critical for the nurse to include to ensure client
safety?
A. Do not stop the medication abruptly to avoid discontinuation syndrome.
B. Take the medication with a high-fat meal to increase absorption.
C. Expect the full therapeutic effect to occur within 24 to 48 hours.
D. Restrict fluid intake to prevent hyponatremia while on this drug.
Correct Answer: A
,Explanation: Abrupt cessation of SSRIs can lead to a cluster of withdrawal-like symptoms
known as discontinuation syndrome, which includes dizziness and irritability. Clients
should be educated on the importance of tapering the dose under medical supervision.
Furthermore, therapeutic effects typically take 2 to 4 weeks to manifest, which is a key
point for managing patient expectations.
4. A client diagnosed with Bipolar Disorder is in the acute manic phase. Which meal choice is
most appropriate for this client?
A. A large steak with baked potato and a side salad
B. Spaghetti and meatballs with a glass of red wine
C. A bowl of hot vegetable soup with crackers
D. Chicken wraps, an apple, and a carton of milk
Correct Answer: D
Explanation: Clients in an acute manic state often have high energy levels and a short
attention span, making it difficult for them to sit down for a traditional meal. ‘Finger foods’
that are high in protein and calories allow the client to eat while moving around the milieu.
This intervention helps maintain nutritional status and prevents physical exhaustion
during manic episodes.
5. A nurse is assessing a client for Post-Traumatic Stress Disorder (PTSD). Which findings are
characteristic of this disorder? (Select all that apply)
A. Flashbacks and intrusive thoughts of the traumatic event
, B. Hypervigilance and an exaggerated startle response
C. Excessive sleeping and increased appetite
D. Avoidance of places or people associated with the trauma
E. A sudden urge to clean and organize the environment
F. Increased social engagement and talkativeness
Correct Answer: A, B, D
Explanation: PTSD is characterized by three main clusters of symptoms: re-experiencing
(flashbacks), arousal (hypervigilance), and avoidance. These symptoms must persist for
more than one month and cause significant distress or functional impairment. Nursing care
focuses on establishing trust and helping the client develop coping mechanisms for these
distressing symptoms.
6. The nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who performs a
handwashing ritual for 15 minutes every hour. What is the most appropriate initial nursing
intervention?
A. Physically prevent the client from using the sink during ritual times.
B. Allow the client enough time to perform the ritual initially.
C. Explain to the client that their hands are already clean and germs are gone.
D. Provide the client with a detailed schedule of group therapies to attend.
Correct Answer: B
