NSRG 126 Exam 2 V2 | NSRG 126 Mental
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 2) | Ivy Tech
1. A client is pacing the hallway, has a rapid heart rate, and is unable to focus on anything
except a specific piece of lint on their shirt. The nurse recognizes this as which level of
anxiety?
A. Mild anxiety
B. Severe anxiety
C. Moderate anxiety
D. Panic level anxiety
Correct Answer: B
Severe anxiety is characterized by a significantly reduced perceptual field and a focus on
specific details or scattered objects. The client may exhibit physical symptoms like
tachycardia and hyperventilation while struggling to process information. Nursing
interventions should focus on safety and using short, clear instructions.
2. A client diagnosed with Borderline Personality Disorder (BPD) tells the day-shift nurse, ‘You
are the only one who cares, the night nurse is incompetent and cruel.’ This is an example of
which defense mechanism?
A. Reaction formation
,B. Sublimation
C. Projection
D. Splitting
Correct Answer: D
Splitting is a hallmark defense mechanism of Borderline Personality Disorder where
individuals view others as all good or all bad. This inability to integrate the positive and
negative qualities of oneself or others results in unstable relationships. The nursing staff
must maintain consistent boundaries and communication to counteract this behavior.
3. The nurse is reviewing the laboratory results for a client receiving Lithium Carbonate for
Bipolar I Disorder. Which serum lithium level would the nurse document as within the
therapeutic range for maintenance?
A. 0.2 to 0.4 mEq/L
B. 1.5 to 2.0 mEq/L
C. 0.6 to 1.2 mEq/L
D. 2.5 to 3.0 mEq/L
Correct Answer: C
The therapeutic serum range for lithium maintenance is generally accepted as 0.6 to 1.2
mEq/L. Levels below this range are ineffective, while levels above 1.5 mEq/L can lead to
, toxicity. The nurse must monitor renal function and sodium levels, as dehydration and low
sodium can lead to lithium retention and toxicity.
4. A client has been prescribed Phenelzine (Nardil). Which foods must the nurse instruct the
client to strictly avoid to prevent a hypertensive crisis?
A. Apples and oranges
B. Aged cheeses and cured meats
C. Whole grain bread and oats
D. Fresh poultry and eggs
Correct Answer: B
Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a low-tyramine diet.
Tyramine is found in fermented, aged, or cured products and can trigger a massive release
of norepinephrine, leading to a hypertensive crisis. Patients must be educated on reading
labels and avoiding items like sauerkraut, soy sauce, and red wine.
5. A client is admitted with Serotonin Syndrome. Which of the following signs and symptoms
would the nurse expect to assess? Select all that apply.
A. Hypothermia
B. Hyperpyrexia and tachycardia
C. Muscle rigidity and tremors
D. Altered mental status and agitation
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 2) | Ivy Tech
1. A client is pacing the hallway, has a rapid heart rate, and is unable to focus on anything
except a specific piece of lint on their shirt. The nurse recognizes this as which level of
anxiety?
A. Mild anxiety
B. Severe anxiety
C. Moderate anxiety
D. Panic level anxiety
Correct Answer: B
Severe anxiety is characterized by a significantly reduced perceptual field and a focus on
specific details or scattered objects. The client may exhibit physical symptoms like
tachycardia and hyperventilation while struggling to process information. Nursing
interventions should focus on safety and using short, clear instructions.
2. A client diagnosed with Borderline Personality Disorder (BPD) tells the day-shift nurse, ‘You
are the only one who cares, the night nurse is incompetent and cruel.’ This is an example of
which defense mechanism?
A. Reaction formation
,B. Sublimation
C. Projection
D. Splitting
Correct Answer: D
Splitting is a hallmark defense mechanism of Borderline Personality Disorder where
individuals view others as all good or all bad. This inability to integrate the positive and
negative qualities of oneself or others results in unstable relationships. The nursing staff
must maintain consistent boundaries and communication to counteract this behavior.
3. The nurse is reviewing the laboratory results for a client receiving Lithium Carbonate for
Bipolar I Disorder. Which serum lithium level would the nurse document as within the
therapeutic range for maintenance?
A. 0.2 to 0.4 mEq/L
B. 1.5 to 2.0 mEq/L
C. 0.6 to 1.2 mEq/L
D. 2.5 to 3.0 mEq/L
Correct Answer: C
The therapeutic serum range for lithium maintenance is generally accepted as 0.6 to 1.2
mEq/L. Levels below this range are ineffective, while levels above 1.5 mEq/L can lead to
, toxicity. The nurse must monitor renal function and sodium levels, as dehydration and low
sodium can lead to lithium retention and toxicity.
4. A client has been prescribed Phenelzine (Nardil). Which foods must the nurse instruct the
client to strictly avoid to prevent a hypertensive crisis?
A. Apples and oranges
B. Aged cheeses and cured meats
C. Whole grain bread and oats
D. Fresh poultry and eggs
Correct Answer: B
Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that requires a low-tyramine diet.
Tyramine is found in fermented, aged, or cured products and can trigger a massive release
of norepinephrine, leading to a hypertensive crisis. Patients must be educated on reading
labels and avoiding items like sauerkraut, soy sauce, and red wine.
5. A client is admitted with Serotonin Syndrome. Which of the following signs and symptoms
would the nurse expect to assess? Select all that apply.
A. Hypothermia
B. Hyperpyrexia and tachycardia
C. Muscle rigidity and tremors
D. Altered mental status and agitation
