NSRG 126 Final Exam V3 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Final Exam) | Ivy Tech
1. A nurse is communicating with a client who is highly anxious. Which of the following
therapeutic communication techniques should the nurse use first?
A. Offering advice on how to handle stressors
B. Reassuring the client that everything will be fine soon
C. Asking why the client is feeling so anxious
D. Listening actively and using silence to allow the client to process information
Correct Answer: D
Explanation: Active listening and the use of silence are fundamental therapeutic
techniques that allow the client to feel heard and provide space for emotional processing.
Using ‘why’ questions can make a client feel defensive and shut down communication.
Offering advice or false reassurance undermines the client’s autonomy and ignores the
underlying cause of anxiety.
2. A nurse is monitoring a client who is taking Lithium Carbonate for Bipolar Disorder. Which
of the following findings are indicative of lithium toxicity? (Select all that apply.)
A. Coarse hand tremors
B. Confusion and slurred speech
,C. Mild thirst and polyuria
D. Persistent gastrointestinal upset such as severe diarrhea
E. Tinnitus
Correct Answer: A, B, D, E
Explanation: Lithium has a narrow therapeutic range (0.6 to 1.2 mEq/L), and toxicity can
be life-threatening. Signs such as coarse tremors, slurred speech, and severe GI distress
indicate blood levels higher than the therapeutic window. Mild thirst and polyuria are
common side effects that often occur at therapeutic levels rather than toxic levels.
3. A client tells the nurse, ‘I only failed that exam because the teacher doesn’t like me.’ The
nurse should identify this as which defense mechanism?
A. Displacement
B. Rationalization
C. Sublimation
D. Reaction Formation
Correct Answer: B
Explanation: Rationalization involves creating socially acceptable or logical explanations
for behaviors or failures to justify them. In this scenario, the client is avoiding
accountability by blaming the teacher. This differs from displacement, which involves
transferring emotions from one object to another safer target.
,4. A nurse is teaching a client about a new prescription for Fluoxetine. Which statement by
the client indicates an understanding of the teaching?
A. I may experience a decrease in my sexual drive while taking this medication.
B. I should see an improvement in my mood within 24 hours.
C. I can stop taking this medication as soon as I feel better.
D. I need to avoid foods containing tyramine while on this drug.
Correct Answer: A
Explanation: Fluoxetine is an SSRI, and sexual dysfunction is a very common side effect
that clients should be warned about. SSRIs take several weeks to reach full therapeutic
effect, typically two to four weeks. Stopping the medication abruptly can lead to
withdrawal symptoms, and tyramine restrictions apply to MAOIs, not SSRIs.
5. Which ethical principle is the nurse upholding when they support a client’s decision to
refuse a prescribed psychotropic medication?
A. Autonomy
B. Justice
C. Beneficence
D. Fidelity
Correct Answer: A
, Explanation: Autonomy refers to the client’s right to make their own decisions regarding
their healthcare, including the right to refuse treatment. Beneficence is the duty to act in
the best interest of the client. Justice involves treating all clients fairly and equally
regardless of their situation.
6. A client with schizophrenia is experiencing auditory hallucinations and says, ‘The voices are
telling me I am bad.’ Which is the best response by the nurse?
A. The voices are not real; you shouldn’t listen to them.
B. I don’t hear any voices, but I can see that you are hearing something.
C. I don’t hear the voices, but I understand that they are scary for you.
D. What exactly are the voices telling you to do right now?
Correct Answer: B
Explanation: The nurse should acknowledge the client’s experience without validating the
hallucination as reality, a technique known as ‘presenting reality.’ Saying ‘I don’t hear any
voices’ identifies the nurse’s reality, while ‘I see you are hearing something’ validates the
client’s feelings. Asking what the voices are telling them is important for safety (command
hallucinations) but presenting reality is the standard initial therapeutic communication
response for hallucinations.
7. A nurse is caring for a client in the manic phase of Bipolar Disorder. Which of the following
nursing interventions is the priority?
A. Encouraging the client to participate in group therapy sessions
Nursing | Actual Q&A with Rationale (NSRG126
Final Exam) | Ivy Tech
1. A nurse is communicating with a client who is highly anxious. Which of the following
therapeutic communication techniques should the nurse use first?
A. Offering advice on how to handle stressors
B. Reassuring the client that everything will be fine soon
C. Asking why the client is feeling so anxious
D. Listening actively and using silence to allow the client to process information
Correct Answer: D
Explanation: Active listening and the use of silence are fundamental therapeutic
techniques that allow the client to feel heard and provide space for emotional processing.
Using ‘why’ questions can make a client feel defensive and shut down communication.
Offering advice or false reassurance undermines the client’s autonomy and ignores the
underlying cause of anxiety.
2. A nurse is monitoring a client who is taking Lithium Carbonate for Bipolar Disorder. Which
of the following findings are indicative of lithium toxicity? (Select all that apply.)
A. Coarse hand tremors
B. Confusion and slurred speech
,C. Mild thirst and polyuria
D. Persistent gastrointestinal upset such as severe diarrhea
E. Tinnitus
Correct Answer: A, B, D, E
Explanation: Lithium has a narrow therapeutic range (0.6 to 1.2 mEq/L), and toxicity can
be life-threatening. Signs such as coarse tremors, slurred speech, and severe GI distress
indicate blood levels higher than the therapeutic window. Mild thirst and polyuria are
common side effects that often occur at therapeutic levels rather than toxic levels.
3. A client tells the nurse, ‘I only failed that exam because the teacher doesn’t like me.’ The
nurse should identify this as which defense mechanism?
A. Displacement
B. Rationalization
C. Sublimation
D. Reaction Formation
Correct Answer: B
Explanation: Rationalization involves creating socially acceptable or logical explanations
for behaviors or failures to justify them. In this scenario, the client is avoiding
accountability by blaming the teacher. This differs from displacement, which involves
transferring emotions from one object to another safer target.
,4. A nurse is teaching a client about a new prescription for Fluoxetine. Which statement by
the client indicates an understanding of the teaching?
A. I may experience a decrease in my sexual drive while taking this medication.
B. I should see an improvement in my mood within 24 hours.
C. I can stop taking this medication as soon as I feel better.
D. I need to avoid foods containing tyramine while on this drug.
Correct Answer: A
Explanation: Fluoxetine is an SSRI, and sexual dysfunction is a very common side effect
that clients should be warned about. SSRIs take several weeks to reach full therapeutic
effect, typically two to four weeks. Stopping the medication abruptly can lead to
withdrawal symptoms, and tyramine restrictions apply to MAOIs, not SSRIs.
5. Which ethical principle is the nurse upholding when they support a client’s decision to
refuse a prescribed psychotropic medication?
A. Autonomy
B. Justice
C. Beneficence
D. Fidelity
Correct Answer: A
, Explanation: Autonomy refers to the client’s right to make their own decisions regarding
their healthcare, including the right to refuse treatment. Beneficence is the duty to act in
the best interest of the client. Justice involves treating all clients fairly and equally
regardless of their situation.
6. A client with schizophrenia is experiencing auditory hallucinations and says, ‘The voices are
telling me I am bad.’ Which is the best response by the nurse?
A. The voices are not real; you shouldn’t listen to them.
B. I don’t hear any voices, but I can see that you are hearing something.
C. I don’t hear the voices, but I understand that they are scary for you.
D. What exactly are the voices telling you to do right now?
Correct Answer: B
Explanation: The nurse should acknowledge the client’s experience without validating the
hallucination as reality, a technique known as ‘presenting reality.’ Saying ‘I don’t hear any
voices’ identifies the nurse’s reality, while ‘I see you are hearing something’ validates the
client’s feelings. Asking what the voices are telling them is important for safety (command
hallucinations) but presenting reality is the standard initial therapeutic communication
response for hallucinations.
7. A nurse is caring for a client in the manic phase of Bipolar Disorder. Which of the following
nursing interventions is the priority?
A. Encouraging the client to participate in group therapy sessions
