NSRG 126 Exam 2 V3 | NSRG 126 Mental
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 2) | Ivy Tech
1. A nurse is conducting a therapeutic interview with a client who has been diagnosed with
major depressive disorder. The client states, ‘I just don’t see the point in anything anymore.’
Which of the following responses by the nurse is the most therapeutic?
A. ‘Why do you feel like there is no point?’
B. ‘I know how you feel; many people feel this way when they are depressed.’
C. ‘You’re feeling as though life has lost its meaning right now.’
D. ‘You should focus on the positive things in your life.’
Correct Answer: C
This response uses the therapeutic technique of restating or reflection, which encourages
the client to explore their feelings further. It avoids asking ‘why’ questions, which can put
the client on the defensive. By validating the client’s experience, the nurse fosters a
stronger therapeutic alliance and promotes open communication.
2. A nurse is assessing a client who is taking lithium carbonate for the treatment of bipolar
disorder. Which of the following clinical findings should the nurse identify as an early
indicator of lithium toxicity?
A. Fine hand tremors and mild thirst
,B. ‘Coarse hand tremors, diarrhea, and slurred speech’
C. Polyuria and dry mouth
D. Constipation and weight gain
E. Increased appetite and agitation
Correct Answer: B
Early signs of lithium toxicity include gastrointestinal upset, coarse tremors, and
neurological changes such as slurred speech or muscle weakness. These symptoms
typically occur when lithium levels exceed the therapeutic range of 0.6 to 1.2 mEq/L. The
nurse must promptly report these findings to the provider and expect an order for a serum
lithium level test.
3. A nurse is caring for a client who is being admitted for an acute exacerbation of
schizophrenia. The client is experiencing auditory hallucinations and is visibly agitated. Which
of the following actions should the nurse take first?
A. Assess the content of the hallucinations.
B. Administer a PRN dose of haloperidol.
C. Provide the client with a quiet, low-stimulation environment.
D. Teach the client coping strategies to manage the voices.
Correct Answer: A
, The first action the nurse should take using the nursing process is assessment. It is critical
to determine if the hallucinations are command in nature, as this could pose a safety risk to
the client or others. Once safety is assessed, the nurse can then proceed with
environmental management and pharmacological interventions.
4. A client is prescribed phenelzine for treatment-resistant depression. Which of the following
food choices by the client indicates a need for further teaching regarding MAOI therapy?
A. Fresh grilled chicken with steamed broccoli
B. Cottage cheese and sliced apples
C. Scrambled eggs and toast with sugar-free jam
D. A pepperoni pizza with aged cheddar and a glass of red wine
Correct Answer: D
Phenelzine is an MAOI that requires a low-tyramine diet to prevent a hypertensive crisis.
Foods such as aged cheeses, pepperoni, salami, and red wine are high in tyramine and must
be strictly avoided. The nurse should educate the client on the severe headache and
hypertension that can occur if these dietary restrictions are not followed.
5. A nurse is caring for a client with Borderline Personality Disorder who is using splitting as a
defense mechanism. The client tells the nurse, ‘You are the only person who actually cares
about me; the night shift nurses are all mean.’ Which of the following is the appropriate
nursing response?
A. ‘I appreciate that, but the night shift nurses are also very good at their jobs.’
, B. ‘Why do you think the night shift nurses are mean?’
C. ‘I am glad you feel supported, but all of the staff members here work together to provide
your care.’
D. ‘I will talk to the night shift supervisor about your concerns.’
Correct Answer: C
Splitting is a common defense mechanism in clients with Borderline Personality Disorder
where they view people as all good or all bad. The nurse should address this by
maintaining a neutral stance and reinforcing the unity of the treatment team. This
approach prevents the client from manipulating staff members against one another.
6. A nurse is evaluating a client for Generalized Anxiety Disorder (GAD). Which of the
following medications should the nurse expect to be prescribed for long-term management of
this condition rather than acute relief?
A. Alprazolam
B. Lorazepam
C. Buspirone
D. Diazepam
Correct Answer: C
Buspirone is a non-benzodiazepine anxiolytic that is ideal for the long-term management
of GAD because it does not cause physical dependence. Unlike benzodiazepines, it has a
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 2) | Ivy Tech
1. A nurse is conducting a therapeutic interview with a client who has been diagnosed with
major depressive disorder. The client states, ‘I just don’t see the point in anything anymore.’
Which of the following responses by the nurse is the most therapeutic?
A. ‘Why do you feel like there is no point?’
B. ‘I know how you feel; many people feel this way when they are depressed.’
C. ‘You’re feeling as though life has lost its meaning right now.’
D. ‘You should focus on the positive things in your life.’
Correct Answer: C
This response uses the therapeutic technique of restating or reflection, which encourages
the client to explore their feelings further. It avoids asking ‘why’ questions, which can put
the client on the defensive. By validating the client’s experience, the nurse fosters a
stronger therapeutic alliance and promotes open communication.
2. A nurse is assessing a client who is taking lithium carbonate for the treatment of bipolar
disorder. Which of the following clinical findings should the nurse identify as an early
indicator of lithium toxicity?
A. Fine hand tremors and mild thirst
,B. ‘Coarse hand tremors, diarrhea, and slurred speech’
C. Polyuria and dry mouth
D. Constipation and weight gain
E. Increased appetite and agitation
Correct Answer: B
Early signs of lithium toxicity include gastrointestinal upset, coarse tremors, and
neurological changes such as slurred speech or muscle weakness. These symptoms
typically occur when lithium levels exceed the therapeutic range of 0.6 to 1.2 mEq/L. The
nurse must promptly report these findings to the provider and expect an order for a serum
lithium level test.
3. A nurse is caring for a client who is being admitted for an acute exacerbation of
schizophrenia. The client is experiencing auditory hallucinations and is visibly agitated. Which
of the following actions should the nurse take first?
A. Assess the content of the hallucinations.
B. Administer a PRN dose of haloperidol.
C. Provide the client with a quiet, low-stimulation environment.
D. Teach the client coping strategies to manage the voices.
Correct Answer: A
, The first action the nurse should take using the nursing process is assessment. It is critical
to determine if the hallucinations are command in nature, as this could pose a safety risk to
the client or others. Once safety is assessed, the nurse can then proceed with
environmental management and pharmacological interventions.
4. A client is prescribed phenelzine for treatment-resistant depression. Which of the following
food choices by the client indicates a need for further teaching regarding MAOI therapy?
A. Fresh grilled chicken with steamed broccoli
B. Cottage cheese and sliced apples
C. Scrambled eggs and toast with sugar-free jam
D. A pepperoni pizza with aged cheddar and a glass of red wine
Correct Answer: D
Phenelzine is an MAOI that requires a low-tyramine diet to prevent a hypertensive crisis.
Foods such as aged cheeses, pepperoni, salami, and red wine are high in tyramine and must
be strictly avoided. The nurse should educate the client on the severe headache and
hypertension that can occur if these dietary restrictions are not followed.
5. A nurse is caring for a client with Borderline Personality Disorder who is using splitting as a
defense mechanism. The client tells the nurse, ‘You are the only person who actually cares
about me; the night shift nurses are all mean.’ Which of the following is the appropriate
nursing response?
A. ‘I appreciate that, but the night shift nurses are also very good at their jobs.’
, B. ‘Why do you think the night shift nurses are mean?’
C. ‘I am glad you feel supported, but all of the staff members here work together to provide
your care.’
D. ‘I will talk to the night shift supervisor about your concerns.’
Correct Answer: C
Splitting is a common defense mechanism in clients with Borderline Personality Disorder
where they view people as all good or all bad. The nurse should address this by
maintaining a neutral stance and reinforcing the unity of the treatment team. This
approach prevents the client from manipulating staff members against one another.
6. A nurse is evaluating a client for Generalized Anxiety Disorder (GAD). Which of the
following medications should the nurse expect to be prescribed for long-term management of
this condition rather than acute relief?
A. Alprazolam
B. Lorazepam
C. Buspirone
D. Diazepam
Correct Answer: C
Buspirone is a non-benzodiazepine anxiolytic that is ideal for the long-term management
of GAD because it does not cause physical dependence. Unlike benzodiazepines, it has a
