NSRG 126 Exam 4 V3 | NSRG 126 Mental
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 4) | Ivy Tech
1. A nurse is caring for a client who has major depressive disorder and was started on
fluoxetine 2 weeks ago. The client states, ‘I finally have the energy to do what I need to do.’
What is the nurse’s priority action?
A. Monitor the client for improved appetite.
B. Document the improvement in the client’s mood.
C. Encourage the client to attend group therapy.
D. Assess the client for suicidal ideation and intent.
Correct Answer: D
The client is at an increased risk for suicide because the medication provides the energy to
carry out a suicide plan before the depressive mood fully lifts. The nurse must prioritize
assessment of safety and suicidal intent when a client suddenly exhibits increased energy.
This clinical phenomenon is a well-documented risk during the early stages of
antidepressant therapy.
,2. A client diagnosed with Bipolar I Disorder is in the manic phase and is moving rapidly
around the unit, talking loudly and interrupting others. Which of the following nursing
interventions is most appropriate?
A. Place the client in seclusion immediately.
B. Engage the client in a competitive board game.
C. Instruct the client to sit still for 30 minutes.
D. Request a prescription for a high-dose sedative.
E. Provide the client with high-calorie finger foods.
Correct Answer: E
Clients in a manic state often cannot sit down to eat regular meals and are at risk for
exhaustion and malnutrition. Providing high-calorie finger foods allows the client to
maintain nutritional intake while remaining active. This intervention addresses the
physiological needs of the client without resorting to restrictive measures.
3. A nurse is monitoring a client taking lithium carbonate for Bipolar Disorder. The client’s
lithium level is 2.1 mEq/L. Which action should the nurse take?
A. Administer the next scheduled dose.
B. Increase the client’s fluid intake.
C. Request a repeat lab draw for the next morning.
D. Withhold the dose and notify the provider immediately.
, Correct Answer: D
A lithium level of 2.1 mEq/L is considered toxic, as the therapeutic range is generally 0.6
to 1.2 mEq/L. The nurse must withhold the medication to prevent further toxicity and
notify the healthcare provider for emergency intervention. Signs of toxicity at this level can
include blurred vision, ataxia, and severe hypotension.
4. Which of the following findings should a nurse expect in a client diagnosed with Anorexia
Nervosa?
A. Tachycardia and hypertension.
B. Increased bone density.
C. Hyperkalemia and diarrhea.
D. Amenorrhea and lanugo.
Correct Answer: D
Anorexia Nervosa leads to severe malnutrition, which disrupts the endocrine system and
causes amenorrhea. Lanugo, or fine downy hair, grows as the body attempts to insulate
itself due to a lack of subcutaneous fat. These physical manifestations are classic indicators
of the physiological strain caused by starvation.
5. A nurse is assessing a client with Borderline Personality Disorder. Which of the following
behaviors is characteristic of this disorder?
A. Splitting and impulsive behaviors.
B. Extreme social isolation and lack of interest in relationships.
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 4) | Ivy Tech
1. A nurse is caring for a client who has major depressive disorder and was started on
fluoxetine 2 weeks ago. The client states, ‘I finally have the energy to do what I need to do.’
What is the nurse’s priority action?
A. Monitor the client for improved appetite.
B. Document the improvement in the client’s mood.
C. Encourage the client to attend group therapy.
D. Assess the client for suicidal ideation and intent.
Correct Answer: D
The client is at an increased risk for suicide because the medication provides the energy to
carry out a suicide plan before the depressive mood fully lifts. The nurse must prioritize
assessment of safety and suicidal intent when a client suddenly exhibits increased energy.
This clinical phenomenon is a well-documented risk during the early stages of
antidepressant therapy.
,2. A client diagnosed with Bipolar I Disorder is in the manic phase and is moving rapidly
around the unit, talking loudly and interrupting others. Which of the following nursing
interventions is most appropriate?
A. Place the client in seclusion immediately.
B. Engage the client in a competitive board game.
C. Instruct the client to sit still for 30 minutes.
D. Request a prescription for a high-dose sedative.
E. Provide the client with high-calorie finger foods.
Correct Answer: E
Clients in a manic state often cannot sit down to eat regular meals and are at risk for
exhaustion and malnutrition. Providing high-calorie finger foods allows the client to
maintain nutritional intake while remaining active. This intervention addresses the
physiological needs of the client without resorting to restrictive measures.
3. A nurse is monitoring a client taking lithium carbonate for Bipolar Disorder. The client’s
lithium level is 2.1 mEq/L. Which action should the nurse take?
A. Administer the next scheduled dose.
B. Increase the client’s fluid intake.
C. Request a repeat lab draw for the next morning.
D. Withhold the dose and notify the provider immediately.
, Correct Answer: D
A lithium level of 2.1 mEq/L is considered toxic, as the therapeutic range is generally 0.6
to 1.2 mEq/L. The nurse must withhold the medication to prevent further toxicity and
notify the healthcare provider for emergency intervention. Signs of toxicity at this level can
include blurred vision, ataxia, and severe hypotension.
4. Which of the following findings should a nurse expect in a client diagnosed with Anorexia
Nervosa?
A. Tachycardia and hypertension.
B. Increased bone density.
C. Hyperkalemia and diarrhea.
D. Amenorrhea and lanugo.
Correct Answer: D
Anorexia Nervosa leads to severe malnutrition, which disrupts the endocrine system and
causes amenorrhea. Lanugo, or fine downy hair, grows as the body attempts to insulate
itself due to a lack of subcutaneous fat. These physical manifestations are classic indicators
of the physiological strain caused by starvation.
5. A nurse is assessing a client with Borderline Personality Disorder. Which of the following
behaviors is characteristic of this disorder?
A. Splitting and impulsive behaviors.
B. Extreme social isolation and lack of interest in relationships.
