NSRG 126 Exam 3 V1 | 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 I Disorder, currently
in a manic phase. Which of the following nursing interventions is the priority?
A. Provide high-calorie, portable finger foods to maintain nutrition.
B. Encourage the client to participate in group therapy sessions.
C. Administer sedative medications to ensure the client sleeps 8 hours.
D. Engage the client in a competitive game of basketball to release energy.
Correct Answer: A
Explanation: During a manic episode, clients are often too hyperactive to sit down for full
meals, making finger foods essential for maintaining caloric intake. Safety and physiological
integrity are the primary nursing concerns during the acute phase of mania. Competitive
activities should be avoided as they can further escalate the client’s agitation and
impulsivity.
2. A nurse is caring for a client who has been taking Lithium Carbonate for three weeks.
Which of the following laboratory values should be reported to the provider immediately?
A. Serum Lithium level of 0.8 mEq/L
B. Sodium level of 140 mEq/L
,C. Serum Lithium level of 1.8 mEq/L
D. WBC count of 8,000/mm3
Correct Answer: C
Explanation: A serum lithium level of 1.8 mEq/L indicates moderate toxicity, as the
therapeutic range is typically 0.6 to 1.2 mEq/L for maintenance. Toxicity can lead to serious
neurological and renal complications if not addressed promptly by the healthcare team.
The nurse must monitor for clinical signs such as coarse tremors, confusion, and ataxia
when levels exceed the therapeutic window.
3. A client diagnosed with Borderline Personality Disorder (BPD) is being treated on an
inpatient unit. Which behavior is most characteristic of this disorder?
A. Social withdrawal and lack of interest in relationships.
B. Splitting, or alternating between over-idealizing and devaluing staff.
C. Arrogance and a grandiosity regarding personal achievements.
D. Excessive preoccupation with orderliness and perfectionism.
Correct Answer: B
Explanation: Splitting is a primary defense mechanism used by individuals with
Borderline Personality Disorder to manage their intense fear of abandonment. This
behavior manifests as seeing people as either all good or all bad, which often creates
conflict among the nursing staff. Consistent limit setting and a unified treatment plan are
essential interventions when managing splitting behaviors.
,4. A nurse is assessing a client for Major Depressive Disorder (MDD). Which of the following
findings are considered classic vegetative signs of depression? (Select all that apply)
A. Psychomotor agitation
B. Insomnia or hypersomnia
C. Anorexia or overeating
D. Feelings of worthlessness
E. Constipation
F. Loss of libido
Correct Answer: B, C, E, F
Explanation: Vegetative signs refer to alterations in physiological functioning that occur
during a depressive episode. These include changes in sleep patterns, appetite, bowel
movements, and sexual desire. Identifying these signs is crucial for comprehensive nursing
care and evaluating the client’s response to antidepressant therapy.
5. A client is prescribed Phenelzine (Nardil) for treatment-resistant depression. Which food
item should the nurse instruct the client to avoid?
A. Fresh chicken breast
B. Cottage cheese
C. Whole grain bread
D. Aged cheddar cheese
, Correct Answer: D
Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI), which requires a low-
tyramine diet to prevent a hypertensive crisis. Aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided by the client. The nurse should
provide a comprehensive list of safe and unsafe foods to ensure the client’s safety during
medication therapy.
6. A nurse is performing a suicide risk assessment. Which statement by the client indicates
the highest level of lethality?
A. I have a loaded gun in my garage and I plan to use it tonight.
B. I have been thinking about ending it all lately.
C. My family would be better off if I weren’t here.
D. I wish I could just sleep and never wake up again.
E. I feel hopeless and I don’t see a future for myself.
Correct Answer: A
Explanation: Lethality is determined by the specificity of the plan and the availability of
the means to carry it out. Having a specific method (a gun), a specific location (garage), and
a specific timeframe (tonight) constitutes an immediate emergency. The nurse must
implement one-to-one observation and immediate safety precautions for this client.
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 I Disorder, currently
in a manic phase. Which of the following nursing interventions is the priority?
A. Provide high-calorie, portable finger foods to maintain nutrition.
B. Encourage the client to participate in group therapy sessions.
C. Administer sedative medications to ensure the client sleeps 8 hours.
D. Engage the client in a competitive game of basketball to release energy.
Correct Answer: A
Explanation: During a manic episode, clients are often too hyperactive to sit down for full
meals, making finger foods essential for maintaining caloric intake. Safety and physiological
integrity are the primary nursing concerns during the acute phase of mania. Competitive
activities should be avoided as they can further escalate the client’s agitation and
impulsivity.
2. A nurse is caring for a client who has been taking Lithium Carbonate for three weeks.
Which of the following laboratory values should be reported to the provider immediately?
A. Serum Lithium level of 0.8 mEq/L
B. Sodium level of 140 mEq/L
,C. Serum Lithium level of 1.8 mEq/L
D. WBC count of 8,000/mm3
Correct Answer: C
Explanation: A serum lithium level of 1.8 mEq/L indicates moderate toxicity, as the
therapeutic range is typically 0.6 to 1.2 mEq/L for maintenance. Toxicity can lead to serious
neurological and renal complications if not addressed promptly by the healthcare team.
The nurse must monitor for clinical signs such as coarse tremors, confusion, and ataxia
when levels exceed the therapeutic window.
3. A client diagnosed with Borderline Personality Disorder (BPD) is being treated on an
inpatient unit. Which behavior is most characteristic of this disorder?
A. Social withdrawal and lack of interest in relationships.
B. Splitting, or alternating between over-idealizing and devaluing staff.
C. Arrogance and a grandiosity regarding personal achievements.
D. Excessive preoccupation with orderliness and perfectionism.
Correct Answer: B
Explanation: Splitting is a primary defense mechanism used by individuals with
Borderline Personality Disorder to manage their intense fear of abandonment. This
behavior manifests as seeing people as either all good or all bad, which often creates
conflict among the nursing staff. Consistent limit setting and a unified treatment plan are
essential interventions when managing splitting behaviors.
,4. A nurse is assessing a client for Major Depressive Disorder (MDD). Which of the following
findings are considered classic vegetative signs of depression? (Select all that apply)
A. Psychomotor agitation
B. Insomnia or hypersomnia
C. Anorexia or overeating
D. Feelings of worthlessness
E. Constipation
F. Loss of libido
Correct Answer: B, C, E, F
Explanation: Vegetative signs refer to alterations in physiological functioning that occur
during a depressive episode. These include changes in sleep patterns, appetite, bowel
movements, and sexual desire. Identifying these signs is crucial for comprehensive nursing
care and evaluating the client’s response to antidepressant therapy.
5. A client is prescribed Phenelzine (Nardil) for treatment-resistant depression. Which food
item should the nurse instruct the client to avoid?
A. Fresh chicken breast
B. Cottage cheese
C. Whole grain bread
D. Aged cheddar cheese
, Correct Answer: D
Explanation: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI), which requires a low-
tyramine diet to prevent a hypertensive crisis. Aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided by the client. The nurse should
provide a comprehensive list of safe and unsafe foods to ensure the client’s safety during
medication therapy.
6. A nurse is performing a suicide risk assessment. Which statement by the client indicates
the highest level of lethality?
A. I have a loaded gun in my garage and I plan to use it tonight.
B. I have been thinking about ending it all lately.
C. My family would be better off if I weren’t here.
D. I wish I could just sleep and never wake up again.
E. I feel hopeless and I don’t see a future for myself.
Correct Answer: A
Explanation: Lethality is determined by the specificity of the plan and the availability of
the means to carry it out. Having a specific method (a gun), a specific location (garage), and
a specific timeframe (tonight) constitutes an immediate emergency. The nurse must
implement one-to-one observation and immediate safety precautions for this client.
