NSRG 126 Final Exam V1 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Final Exam) | Ivy Tech
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is most therapeutic?
A. I don’t hear the voices, but I can see that you are frightened.
B. The voices are not real; they are just a symptom of your illness.
C. Why do you think the voices are telling you those things?
D. I understand the voices are real to you, but I do not hear anything.
Correct Answer: D
Explanation: This response acknowledges the client’s reality while presenting the nurse’s
reality without dismissing the client’s experience. It follows the therapeutic technique of
presenting reality to a patient experiencing hallucinations. Validating the client’s feelings
while clarifying that the nurse does not share the perception helps build trust and maintain
a connection to reality.
2. Which of the following are components of a standard Mental Status Examination (MSE)?
A. All of the above
B. Mood and affect
C. Thought process and content
,D. Cognition and insight
E. Appearance and behavior
Correct Answer: A
Explanation: A complete Mental Status Examination evaluates multiple domains including
appearance, behavior, mood, affect, speech, thought process, thought content, and cognitive
functions. This systematic assessment allows the clinician to identify specific areas of
dysfunction in a client’s current mental functioning. Each component provides critical data
that informs the psychiatric diagnosis and nursing care plan.
3. A client is prescribed Lithium Carbonate for Bipolar Disorder. The nurse should instruct the
client to maintain a consistent intake of which substance?
A. Potassium
B. Calcium
C. Sodium
D. Vitamin B12
Correct Answer: C
Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
If sodium levels drop, the kidneys retain lithium, leading to potentially toxic levels. Clients
must be taught to avoid sudden changes in sodium intake or excessive sweating without
fluid replacement to prevent lithium toxicity.
,4. A patient with borderline personality disorder frequently alternates between over-
idealizing and devaluing the nursing staff. This defense mechanism is known as:
A. Projection
B. Reaction Formation
C. Sublimation
D. Displacement
E. Intellectualization
F. Splitting
Correct Answer: F
Explanation: Splitting is a primitive defense mechanism common in borderline personality
disorder where individuals see others as ‘all good’ or ‘all bad.’ This occurs because the
individual cannot integrate the positive and negative qualities of a person into a cohesive
image. Nursing staff must use a consistent, team-based approach to minimize the
disruptive effects of splitting behavior on the unit.
5. An older adult client is admitted with sudden onset confusion and agitation. The nurse
suspects delirium rather than dementia based on which finding?
A. Rapid onset of symptoms
B. Gradual loss of memory
C. Presence of aphasia
, D. History of Alzheimer’s disease
Correct Answer: A
Explanation: Delirium is characterized by an acute, rapid onset of confusion, fluctuating
consciousness, and reversible causes, such as infection or medication toxicity. In contrast,
dementia follows a slow, progressive, and irreversible course of cognitive decline.
Differentiating these two is critical because delirium is often a medical emergency
requiring immediate treatment of the underlying cause.
6. Which side effect of first-generation antipsychotics is characterized by involuntary
movements of the tongue and face?
A. Akathisia
B. Tardive dyskinesia
C. Pseudoparkinsonism
D. Dystonia
E. Neuroleptic Malignant Syndrome
Correct Answer: B
Explanation: Tardive dyskinesia (TD) is a serious, often irreversible extrapyramidal side
effect involving rhythmic, involuntary movements, typically of the face and mouth. It
usually occurs after long-term use of conventional antipsychotics like haloperidol. Nurses
should use the AIMS (Abnormal Involuntary Movement Scale) to regularly screen patients
for early signs of TD.
Nursing | Actual Q&A with Rationale (NSRG126
Final Exam) | Ivy Tech
1. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is most therapeutic?
A. I don’t hear the voices, but I can see that you are frightened.
B. The voices are not real; they are just a symptom of your illness.
C. Why do you think the voices are telling you those things?
D. I understand the voices are real to you, but I do not hear anything.
Correct Answer: D
Explanation: This response acknowledges the client’s reality while presenting the nurse’s
reality without dismissing the client’s experience. It follows the therapeutic technique of
presenting reality to a patient experiencing hallucinations. Validating the client’s feelings
while clarifying that the nurse does not share the perception helps build trust and maintain
a connection to reality.
2. Which of the following are components of a standard Mental Status Examination (MSE)?
A. All of the above
B. Mood and affect
C. Thought process and content
,D. Cognition and insight
E. Appearance and behavior
Correct Answer: A
Explanation: A complete Mental Status Examination evaluates multiple domains including
appearance, behavior, mood, affect, speech, thought process, thought content, and cognitive
functions. This systematic assessment allows the clinician to identify specific areas of
dysfunction in a client’s current mental functioning. Each component provides critical data
that informs the psychiatric diagnosis and nursing care plan.
3. A client is prescribed Lithium Carbonate for Bipolar Disorder. The nurse should instruct the
client to maintain a consistent intake of which substance?
A. Potassium
B. Calcium
C. Sodium
D. Vitamin B12
Correct Answer: C
Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in the body.
If sodium levels drop, the kidneys retain lithium, leading to potentially toxic levels. Clients
must be taught to avoid sudden changes in sodium intake or excessive sweating without
fluid replacement to prevent lithium toxicity.
,4. A patient with borderline personality disorder frequently alternates between over-
idealizing and devaluing the nursing staff. This defense mechanism is known as:
A. Projection
B. Reaction Formation
C. Sublimation
D. Displacement
E. Intellectualization
F. Splitting
Correct Answer: F
Explanation: Splitting is a primitive defense mechanism common in borderline personality
disorder where individuals see others as ‘all good’ or ‘all bad.’ This occurs because the
individual cannot integrate the positive and negative qualities of a person into a cohesive
image. Nursing staff must use a consistent, team-based approach to minimize the
disruptive effects of splitting behavior on the unit.
5. An older adult client is admitted with sudden onset confusion and agitation. The nurse
suspects delirium rather than dementia based on which finding?
A. Rapid onset of symptoms
B. Gradual loss of memory
C. Presence of aphasia
, D. History of Alzheimer’s disease
Correct Answer: A
Explanation: Delirium is characterized by an acute, rapid onset of confusion, fluctuating
consciousness, and reversible causes, such as infection or medication toxicity. In contrast,
dementia follows a slow, progressive, and irreversible course of cognitive decline.
Differentiating these two is critical because delirium is often a medical emergency
requiring immediate treatment of the underlying cause.
6. Which side effect of first-generation antipsychotics is characterized by involuntary
movements of the tongue and face?
A. Akathisia
B. Tardive dyskinesia
C. Pseudoparkinsonism
D. Dystonia
E. Neuroleptic Malignant Syndrome
Correct Answer: B
Explanation: Tardive dyskinesia (TD) is a serious, often irreversible extrapyramidal side
effect involving rhythmic, involuntary movements, typically of the face and mouth. It
usually occurs after long-term use of conventional antipsychotics like haloperidol. Nurses
should use the AIMS (Abnormal Involuntary Movement Scale) to regularly screen patients
for early signs of TD.
