,NUR 256 Exam 2 – Mental Health Nursing –
Actual Q&A (GCN) (Updated PDF)
1. A client with schizophrenia tells the nurse, "The FBI has planted a chip in my
brain to steal my ideas." The nurse identifies this statement as which type of
thought content?
A) Obsession
B) Delusion
C) Hallucination
D) Illusion
Correct Answer: B) Delusion
Rationale: A delusion is a fixed, false belief not based in reality. The client's
statement reflects a persecutory delusion. Hallucinations are false sensory
perceptions, while obsessions are recurrent intrusive thoughts. Illusions involve
misinterpretation of real stimuli.
2. A patient with major depressive disorder is started on fluoxetine. The nurse
explains that this medication increases the availability of serotonin by which
mechanism?
A) Blocking dopamine receptors
B) Inhibiting monoamine oxidase
C) Blocking serotonin reuptake
D) Enhancing GABA binding
Correct Answer: C) Blocking serotonin reuptake
,Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that
blocks the reuptake of serotonin into the presynaptic neuron, increasing its
availability in the synaptic cleft. It does not block dopamine receptors, inhibit
MAO, or directly enhance GABA.
3. A client experiences a pounding heart, tremors, and a narrowed perceptual
field but remains able to follow simple directions. Which level of anxiety does
the nurse document?
A) Mild
B) Moderate
C) Severe
D) Panic
Correct Answer: B) Moderate
Rationale: Moderate anxiety narrows the perceptual field and causes physical
symptoms such as tachycardia and tremors, yet the person can still process
information when guided. Severe anxiety drastically reduces problem-solving
ability; panic involves loss of reality contact.
4. During a group therapy session, a member says, "Hearing that you also
struggle with guilt makes me feel less alone." This statement best reflects which
of Yalom's therapeutic factors?
A) Catharsis
B) Altruism
C) Universality
, D) Instillation of hope
Correct Answer: C) Universality
Rationale: Universality is the recognition that others share similar feelings and
problems, reducing isolation. The client's statement directly describes a sense of
shared experience. Altruism involves helping others, while instillation of hope is
about seeing improvement in peers.
5. A nurse is caring for a client with Alzheimer's disease who becomes agitated
and repeatedly asks to go home. Which intervention is most appropriate?
A) Remind the client that this is their home
B) Explore the underlying emotional need and provide reassurance
C) Place the client in a room with the television on for distraction
D) Firmly redirect the client to another activity
Correct Answer: B) Explore the underlying emotional need and provide
reassurance
Rationale: Validation therapy acknowledges the client's feelings rather than
correcting the memory. Exploring the emotion and providing reassurance
reduces anxiety. Reality orientation may increase agitation; distraction alone
does not address the emotional need.
6. A patient with panic-level anxiety is pacing, screaming, and unable to follow
commands. The priority nursing action is to:
A) Administer a PRN benzodiazepine immediately
Actual Q&A (GCN) (Updated PDF)
1. A client with schizophrenia tells the nurse, "The FBI has planted a chip in my
brain to steal my ideas." The nurse identifies this statement as which type of
thought content?
A) Obsession
B) Delusion
C) Hallucination
D) Illusion
Correct Answer: B) Delusion
Rationale: A delusion is a fixed, false belief not based in reality. The client's
statement reflects a persecutory delusion. Hallucinations are false sensory
perceptions, while obsessions are recurrent intrusive thoughts. Illusions involve
misinterpretation of real stimuli.
2. A patient with major depressive disorder is started on fluoxetine. The nurse
explains that this medication increases the availability of serotonin by which
mechanism?
A) Blocking dopamine receptors
B) Inhibiting monoamine oxidase
C) Blocking serotonin reuptake
D) Enhancing GABA binding
Correct Answer: C) Blocking serotonin reuptake
,Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that
blocks the reuptake of serotonin into the presynaptic neuron, increasing its
availability in the synaptic cleft. It does not block dopamine receptors, inhibit
MAO, or directly enhance GABA.
3. A client experiences a pounding heart, tremors, and a narrowed perceptual
field but remains able to follow simple directions. Which level of anxiety does
the nurse document?
A) Mild
B) Moderate
C) Severe
D) Panic
Correct Answer: B) Moderate
Rationale: Moderate anxiety narrows the perceptual field and causes physical
symptoms such as tachycardia and tremors, yet the person can still process
information when guided. Severe anxiety drastically reduces problem-solving
ability; panic involves loss of reality contact.
4. During a group therapy session, a member says, "Hearing that you also
struggle with guilt makes me feel less alone." This statement best reflects which
of Yalom's therapeutic factors?
A) Catharsis
B) Altruism
C) Universality
, D) Instillation of hope
Correct Answer: C) Universality
Rationale: Universality is the recognition that others share similar feelings and
problems, reducing isolation. The client's statement directly describes a sense of
shared experience. Altruism involves helping others, while instillation of hope is
about seeing improvement in peers.
5. A nurse is caring for a client with Alzheimer's disease who becomes agitated
and repeatedly asks to go home. Which intervention is most appropriate?
A) Remind the client that this is their home
B) Explore the underlying emotional need and provide reassurance
C) Place the client in a room with the television on for distraction
D) Firmly redirect the client to another activity
Correct Answer: B) Explore the underlying emotional need and provide
reassurance
Rationale: Validation therapy acknowledges the client's feelings rather than
correcting the memory. Exploring the emotion and providing reassurance
reduces anxiety. Reality orientation may increase agitation; distraction alone
does not address the emotional need.
6. A patient with panic-level anxiety is pacing, screaming, and unable to follow
commands. The priority nursing action is to:
A) Administer a PRN benzodiazepine immediately
