,NUR253/NUR 253 Exam 2 | Mental Health Nursing
Concepts | Galen College | 26/27 (PDF)
1. The nurse is caring for a client who is dying. The client states, "My mother died in the hospital, but I
did not get there before she died." Which response by the nurse is most therapeutic?
A) "We will call your family in time for them to get here."
B) "I wonder if you are fearful of dying alone."
C) "I will make sure a staff member is in your room at all times."
D) "I will tell your family of your concern so that they can be here."
Correct Answer: I wonder if you are fearful of dying alone.
Rationale: This response uses the therapeutic technique of exploring feelings, acknowledging the
client's implied fear and opening the door for further discussion about emotions regarding dying
alone. The other options offer false reassurance, make unkeepable promises, or avoid addressing the
client's emotional needs.
2. A client experiencing a manic episode is being admitted to the unit. Which room assignment should
the nurse plan for this client?
A) A private room in a quiet location on the unit
B) A semi-private room with a roommate who has a similar diagnosis
C) A private room close to the nursing station
D) A seclusion room until the client's activity level becomes more subdued
Correct Answer: A private room close to the nursing station
Rationale: A client in the manic phase requires a safe environment with reduced stimulation but close
supervision. A private room near the nursing station allows for monitoring while minimizing
interaction with others that could escalate mania. Seclusion is not an initial assignment, and a
roommate would be overstimulating.
,3. The nurse is assessing a young adult client who reports increased anxiety and an inability to
concentrate. Which response should the nurse make?
A) "It sounds like you're having a difficult time."
B) "Have you talked to your parents about this yet?"
C) "Why do you think you are so anxious?"
D) "How long has this been going on?"
Correct Answer: How long has this been going on?
Rationale: This question gathers essential assessment data by exploring the duration of the
symptoms. It is a direct, factual question that helps the nurse understand the timeline of the client's
problem. Options A, B, and C are either vague, make assumptions, or use "why" questions which can
make a client feel defensive.
4. A client hospitalized for major depressive disorder has been withdrawn for several days. Today the
client is suddenly calm, eating meals, and giving away personal belongings. What is the nurse's
priority concern?
A) Improvement in mood
B) Medication effectiveness
C) Imminent suicide risk
D) Social withdrawal
Correct Answer: Imminent suicide risk
Rationale: Sudden calmness combined with giving away belongings is a classic pre-suicide warning
sign. A sudden shift from severe depression to apparent calmness can indicate that the client has
made a decision to end their life and feels at peace with that decision.
5. The nurse is caring for a client prescribed haloperidol for severe manifestations of schizophrenia.
The nurse should assess the client for which adverse effect?
A) Dysrhythmias
B) Cataracts
, C) Pancreatitis
D) Bleeding
Correct Answer: Dysrhythmias
Rationale: Haloperidol, an antipsychotic medication, can prolong the QT interval, leading to a risk of
serious dysrhythmias like Torsades de Pointes. This is a critical adverse effect that requires monitoring
through electrocardiograms.
6. A client with panic disorder arrives in the emergency department hyperventilating, trembling, and
stating, "I'm dying!" Which action should the nurse take first?
A) Teach the client slow breathing techniques
B) Administer a PRN benzodiazepine
C) Remain with the client and maintain a calm, quiet environment
D) Encourage the client to verbalize feelings about the attack
Correct Answer: Remain with the client and maintain a calm, quiet environment
Rationale: During a panic attack, the priority is to provide a safe, calming presence to help the client
feel secure and reduce stimuli that may escalate anxiety. Teaching techniques or encouraging
verbalization is not appropriate during the peak of the attack when the client cannot process new
information.
7. A client with schizophrenia tells the nurse, "The voices are telling me that the food is poisoned."
Which nursing action is the priority?
A) Reassure the client that the food is safe and not poisoned
B) Document the client's statement and continue with mealtime
C) Assess the client for risk of harm and explore the content of the hallucination
D) Administer a PRN antipsychotic medication immediately
Correct Answer: Assess the client for risk of harm and explore the content of the hallucination
Concepts | Galen College | 26/27 (PDF)
1. The nurse is caring for a client who is dying. The client states, "My mother died in the hospital, but I
did not get there before she died." Which response by the nurse is most therapeutic?
A) "We will call your family in time for them to get here."
B) "I wonder if you are fearful of dying alone."
C) "I will make sure a staff member is in your room at all times."
D) "I will tell your family of your concern so that they can be here."
Correct Answer: I wonder if you are fearful of dying alone.
Rationale: This response uses the therapeutic technique of exploring feelings, acknowledging the
client's implied fear and opening the door for further discussion about emotions regarding dying
alone. The other options offer false reassurance, make unkeepable promises, or avoid addressing the
client's emotional needs.
2. A client experiencing a manic episode is being admitted to the unit. Which room assignment should
the nurse plan for this client?
A) A private room in a quiet location on the unit
B) A semi-private room with a roommate who has a similar diagnosis
C) A private room close to the nursing station
D) A seclusion room until the client's activity level becomes more subdued
Correct Answer: A private room close to the nursing station
Rationale: A client in the manic phase requires a safe environment with reduced stimulation but close
supervision. A private room near the nursing station allows for monitoring while minimizing
interaction with others that could escalate mania. Seclusion is not an initial assignment, and a
roommate would be overstimulating.
,3. The nurse is assessing a young adult client who reports increased anxiety and an inability to
concentrate. Which response should the nurse make?
A) "It sounds like you're having a difficult time."
B) "Have you talked to your parents about this yet?"
C) "Why do you think you are so anxious?"
D) "How long has this been going on?"
Correct Answer: How long has this been going on?
Rationale: This question gathers essential assessment data by exploring the duration of the
symptoms. It is a direct, factual question that helps the nurse understand the timeline of the client's
problem. Options A, B, and C are either vague, make assumptions, or use "why" questions which can
make a client feel defensive.
4. A client hospitalized for major depressive disorder has been withdrawn for several days. Today the
client is suddenly calm, eating meals, and giving away personal belongings. What is the nurse's
priority concern?
A) Improvement in mood
B) Medication effectiveness
C) Imminent suicide risk
D) Social withdrawal
Correct Answer: Imminent suicide risk
Rationale: Sudden calmness combined with giving away belongings is a classic pre-suicide warning
sign. A sudden shift from severe depression to apparent calmness can indicate that the client has
made a decision to end their life and feels at peace with that decision.
5. The nurse is caring for a client prescribed haloperidol for severe manifestations of schizophrenia.
The nurse should assess the client for which adverse effect?
A) Dysrhythmias
B) Cataracts
, C) Pancreatitis
D) Bleeding
Correct Answer: Dysrhythmias
Rationale: Haloperidol, an antipsychotic medication, can prolong the QT interval, leading to a risk of
serious dysrhythmias like Torsades de Pointes. This is a critical adverse effect that requires monitoring
through electrocardiograms.
6. A client with panic disorder arrives in the emergency department hyperventilating, trembling, and
stating, "I'm dying!" Which action should the nurse take first?
A) Teach the client slow breathing techniques
B) Administer a PRN benzodiazepine
C) Remain with the client and maintain a calm, quiet environment
D) Encourage the client to verbalize feelings about the attack
Correct Answer: Remain with the client and maintain a calm, quiet environment
Rationale: During a panic attack, the priority is to provide a safe, calming presence to help the client
feel secure and reduce stimuli that may escalate anxiety. Teaching techniques or encouraging
verbalization is not appropriate during the peak of the attack when the client cannot process new
information.
7. A client with schizophrenia tells the nurse, "The voices are telling me that the food is poisoned."
Which nursing action is the priority?
A) Reassure the client that the food is safe and not poisoned
B) Document the client's statement and continue with mealtime
C) Assess the client for risk of harm and explore the content of the hallucination
D) Administer a PRN antipsychotic medication immediately
Correct Answer: Assess the client for risk of harm and explore the content of the hallucination
