NUR 253 Exam 4 Mental
Health PDF | Galen
College of Nursing
1. A client with major depressive disorder says, “My family would be better off
without me.” What is the nurse’s priority response?
A. “Your family needs you.”
B. “Why do you think your family feels that way?”
C. “Are you thinking about killing yourself?”
D. “You should focus on the positive things in your life.”
Answer: C.
Rationale: Directly assessing suicidal thoughts is the priority. Asking about suicide
does not increase suicidal behavior and helps determine immediate safety needs.
2. Which finding is most characteristic of mania?
A. Social withdrawal
B. Increased need for sleep
C. Flight of ideas
D. Psychomotor retardation
Answer: C.
Rationale: Mania commonly involves elevated or irritable mood, decreased need for
sleep, pressured speech, and flight of ideas.
,3. A client experiencing a panic attack is hyperventilating and trembling. What should
the nurse do first?
A. Ask the client to describe the source of anxiety.
B. Leave the client alone in a quiet room.
C. Stay with the client and use short, simple statements.
D. Encourage the client to discuss childhood experiences.
Answer: C.
Rationale: During severe anxiety or panic, the client's ability to process information is
reduced. Remaining with the client and providing simple directions promotes safety.
4. A client with schizophrenia says, “The voices are telling me that someone is going
to hurt me.” What is the nurse’s best response?
A. “The voices aren't real, so ignore them.”
B. “I don't hear the voices, but I understand that you hear them.”
C. “What did you do to make the voices angry?”
D. “You need to stop listening to them.”
Answer: B.
Rationale: The nurse should acknowledge the client's experience without validating
the hallucination as reality.
5. Which behavior is most suggestive of obsessive-compulsive disorder (OCD)?
A. Repeatedly checking that a door is locked
B. Hearing voices commenting on behavior
C. Rapidly changing from happiness to sadness
D. Avoiding all social interactions
,Answer: A.
Rationale: Compulsions are repetitive behaviors performed to reduce anxiety
associated with intrusive thoughts or obsessions.
6. A client taking lithium reports severe diarrhea, vomiting, muscle weakness, and
worsening tremors. What should the nurse suspect?
A. Therapeutic response
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: B.
Rationale: Severe gastrointestinal symptoms, coarse tremor, weakness, and
neurologic changes can indicate lithium toxicity and require prompt evaluation.
7. Which intervention is appropriate for a client experiencing acute psychosis?
A. Encourage extensive group discussion.
B. Provide lengthy explanations.
C. Maintain a calm, low-stimulation environment.
D. Challenge every delusional statement.
Answer: C.
Rationale: Reducing environmental stimulation can decrease agitation and help the
client maintain behavioral control.
8. A client with anorexia nervosa has a heart rate of 42/min and reports dizziness.
What is the nurse's priority?
A. Discuss body image concerns.
B. Encourage participation in group therapy.
, C. Assess cardiovascular stability and notify the provider.
D. Ask the client to identify foods they dislike.
Answer: C.
Rationale: Severe bradycardia and dizziness can indicate potentially life-threatening
physiologic complications of restrictive eating disorders.
9. Which symptom is commonly associated with post-traumatic stress disorder
(PTSD)?
A. Flashbacks
B. Increased appetite only
C. Grandiosity
D. Echolalia
Answer: A.
Rationale: PTSD can involve intrusive memories, nightmares, flashbacks, avoidance,
hyperarousal, and negative changes in mood or cognition.
10. A client experiencing alcohol withdrawal develops severe agitation, confusion,
tremors, and visual hallucinations. What complication should the nurse suspect?
A. Delirium tremens
B. Opioid intoxication
C. Wernicke-Korsakoff syndrome
D. Major depressive disorder
Answer: A.
Rationale: Delirium tremens is a severe form of alcohol withdrawal characterized by
autonomic hyperactivity, confusion, agitation, and hallucinations.
11. Which finding is most consistent with opioid overdose?
Health PDF | Galen
College of Nursing
1. A client with major depressive disorder says, “My family would be better off
without me.” What is the nurse’s priority response?
A. “Your family needs you.”
B. “Why do you think your family feels that way?”
C. “Are you thinking about killing yourself?”
D. “You should focus on the positive things in your life.”
Answer: C.
Rationale: Directly assessing suicidal thoughts is the priority. Asking about suicide
does not increase suicidal behavior and helps determine immediate safety needs.
2. Which finding is most characteristic of mania?
A. Social withdrawal
B. Increased need for sleep
C. Flight of ideas
D. Psychomotor retardation
Answer: C.
Rationale: Mania commonly involves elevated or irritable mood, decreased need for
sleep, pressured speech, and flight of ideas.
,3. A client experiencing a panic attack is hyperventilating and trembling. What should
the nurse do first?
A. Ask the client to describe the source of anxiety.
B. Leave the client alone in a quiet room.
C. Stay with the client and use short, simple statements.
D. Encourage the client to discuss childhood experiences.
Answer: C.
Rationale: During severe anxiety or panic, the client's ability to process information is
reduced. Remaining with the client and providing simple directions promotes safety.
4. A client with schizophrenia says, “The voices are telling me that someone is going
to hurt me.” What is the nurse’s best response?
A. “The voices aren't real, so ignore them.”
B. “I don't hear the voices, but I understand that you hear them.”
C. “What did you do to make the voices angry?”
D. “You need to stop listening to them.”
Answer: B.
Rationale: The nurse should acknowledge the client's experience without validating
the hallucination as reality.
5. Which behavior is most suggestive of obsessive-compulsive disorder (OCD)?
A. Repeatedly checking that a door is locked
B. Hearing voices commenting on behavior
C. Rapidly changing from happiness to sadness
D. Avoiding all social interactions
,Answer: A.
Rationale: Compulsions are repetitive behaviors performed to reduce anxiety
associated with intrusive thoughts or obsessions.
6. A client taking lithium reports severe diarrhea, vomiting, muscle weakness, and
worsening tremors. What should the nurse suspect?
A. Therapeutic response
B. Lithium toxicity
C. Serotonin syndrome
D. Neuroleptic malignant syndrome
Answer: B.
Rationale: Severe gastrointestinal symptoms, coarse tremor, weakness, and
neurologic changes can indicate lithium toxicity and require prompt evaluation.
7. Which intervention is appropriate for a client experiencing acute psychosis?
A. Encourage extensive group discussion.
B. Provide lengthy explanations.
C. Maintain a calm, low-stimulation environment.
D. Challenge every delusional statement.
Answer: C.
Rationale: Reducing environmental stimulation can decrease agitation and help the
client maintain behavioral control.
8. A client with anorexia nervosa has a heart rate of 42/min and reports dizziness.
What is the nurse's priority?
A. Discuss body image concerns.
B. Encourage participation in group therapy.
, C. Assess cardiovascular stability and notify the provider.
D. Ask the client to identify foods they dislike.
Answer: C.
Rationale: Severe bradycardia and dizziness can indicate potentially life-threatening
physiologic complications of restrictive eating disorders.
9. Which symptom is commonly associated with post-traumatic stress disorder
(PTSD)?
A. Flashbacks
B. Increased appetite only
C. Grandiosity
D. Echolalia
Answer: A.
Rationale: PTSD can involve intrusive memories, nightmares, flashbacks, avoidance,
hyperarousal, and negative changes in mood or cognition.
10. A client experiencing alcohol withdrawal develops severe agitation, confusion,
tremors, and visual hallucinations. What complication should the nurse suspect?
A. Delirium tremens
B. Opioid intoxication
C. Wernicke-Korsakoff syndrome
D. Major depressive disorder
Answer: A.
Rationale: Delirium tremens is a severe form of alcohol withdrawal characterized by
autonomic hyperactivity, confusion, agitation, and hallucinations.
11. Which finding is most consistent with opioid overdose?
