NSRG 126 Exam 4 V2 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 4) | Ivy Tech
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most appropriate initial nursing intervention?
A. Ask the client what the voices are saying to determine the risk of harm.
B. Provide a quiet, isolated environment to reduce sensory input.
C. Advise the client to ignore the voices and focus on reality.
D. Validate the client’s feelings while stating that you do not hear the voices.
Correct Answer: D
Explanation: The nurse must acknowledge the client’s reality without reinforcing the
hallucination. By validating feelings, the nurse maintains rapport while providing reality
orientation. This approach helps the client feel understood without the nurse agreeing that
the voices are real.
2. A client is being treated with Lithium carbonate for Bipolar I disorder. The nurse monitors
the client’s serum levels closely. Which of the following ranges represents the therapeutic
window for acute mania?
A. 0.8 to 1.4 mEq/L
B. 0.2 to 0.6 mEq/L
,C. 1.5 to 2.0 mEq/L
D. 2.1 to 2.5 mEq/L
E. 0.6 to 1.2 mEq/L
F. 0.4 to 1.0 mEq/L
Correct Answer: A
Explanation: For acute mania, the therapeutic lithium level is slightly higher, typically
between 0.8 and 1.4 mEq/L. Levels above 1.5 mEq/L are considered toxic and require
immediate intervention. Regular monitoring is essential because the therapeutic window is
very narrow.
3. A client with Borderline Personality Disorder is observed praising one nurse while
disparaging another nurse to the staff. This behavior is recognized as:
A. Splitting
B. Projection
C. Idealization
D. Manipulation
Correct Answer: A
Explanation: Splitting is a common defense mechanism where individuals view others as
all good or all bad. This prevents the individual from integrating positive and negative
, qualities of others into a cohesive whole. It often causes conflict among the treatment team
members.
4. The nurse is assessing a client for potential alcohol withdrawal. Which of the following
symptoms would indicate the onset of withdrawal?
A. Fine tremors, tachycardia, and hypertension
B. Bradycardia, hypotension, and somnolence
C. Increased appetite, hypersomnia, and depression
D. Pinpoint pupils, respiratory depression, and slurred speech
Correct Answer: A
Explanation: Alcohol withdrawal typically manifests as autonomic hyperactivity, including
tremors and elevated vital signs. These symptoms usually begin 6 to 8 hours after the last
drink. Identifying these early signs is crucial to preventing progression to delirium
tremens.
5. A client is prescribed Clozapine (Clozaril) for treatment-resistant schizophrenia. Which
laboratory value is the priority for the nurse to monitor?
A. Serum glucose
B. Liver function tests
C. Absolute Neutrophil Count (ANC)
D. Platelet count
Nursing | Actual Q&A with Rationale (NSRG126
Exam 4) | Ivy Tech
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which is the most appropriate initial nursing intervention?
A. Ask the client what the voices are saying to determine the risk of harm.
B. Provide a quiet, isolated environment to reduce sensory input.
C. Advise the client to ignore the voices and focus on reality.
D. Validate the client’s feelings while stating that you do not hear the voices.
Correct Answer: D
Explanation: The nurse must acknowledge the client’s reality without reinforcing the
hallucination. By validating feelings, the nurse maintains rapport while providing reality
orientation. This approach helps the client feel understood without the nurse agreeing that
the voices are real.
2. A client is being treated with Lithium carbonate for Bipolar I disorder. The nurse monitors
the client’s serum levels closely. Which of the following ranges represents the therapeutic
window for acute mania?
A. 0.8 to 1.4 mEq/L
B. 0.2 to 0.6 mEq/L
,C. 1.5 to 2.0 mEq/L
D. 2.1 to 2.5 mEq/L
E. 0.6 to 1.2 mEq/L
F. 0.4 to 1.0 mEq/L
Correct Answer: A
Explanation: For acute mania, the therapeutic lithium level is slightly higher, typically
between 0.8 and 1.4 mEq/L. Levels above 1.5 mEq/L are considered toxic and require
immediate intervention. Regular monitoring is essential because the therapeutic window is
very narrow.
3. A client with Borderline Personality Disorder is observed praising one nurse while
disparaging another nurse to the staff. This behavior is recognized as:
A. Splitting
B. Projection
C. Idealization
D. Manipulation
Correct Answer: A
Explanation: Splitting is a common defense mechanism where individuals view others as
all good or all bad. This prevents the individual from integrating positive and negative
, qualities of others into a cohesive whole. It often causes conflict among the treatment team
members.
4. The nurse is assessing a client for potential alcohol withdrawal. Which of the following
symptoms would indicate the onset of withdrawal?
A. Fine tremors, tachycardia, and hypertension
B. Bradycardia, hypotension, and somnolence
C. Increased appetite, hypersomnia, and depression
D. Pinpoint pupils, respiratory depression, and slurred speech
Correct Answer: A
Explanation: Alcohol withdrawal typically manifests as autonomic hyperactivity, including
tremors and elevated vital signs. These symptoms usually begin 6 to 8 hours after the last
drink. Identifying these early signs is crucial to preventing progression to delirium
tremens.
5. A client is prescribed Clozapine (Clozaril) for treatment-resistant schizophrenia. Which
laboratory value is the priority for the nurse to monitor?
A. Serum glucose
B. Liver function tests
C. Absolute Neutrophil Count (ANC)
D. Platelet count
