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, NUR 253 Exam 2: Mental Health Nursing Concepts
1. A nurse is caring for a client who is dying. The client says, "My mother died
in the hospital, but I did not get there before she died." Which of the following
statements should the nurse make?
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."
The Correct Answer Is B. This response uses the therapeutic technique of
exploring feelings. It acknowledges the client's implied fear and opens the door for
further discussion about their emotions regarding dying alone. The other options
offer false reassurance, make promises that cannot be kept, or avoid addressing the
client's emotional needs.
2. A nurse is caring for a young adult client who says he is experiencing
increased anxiety and an inability to concentrate. Which of the following
responses 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?"
The Correct Answer Is D. 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.
Ascorers
,3. A nurse is admitting a client who is in the manic phase of bipolar disorder.
The nurse should plan to make which of the following room assignments for
the 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.
The Correct Answer Is C. 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 their mania. Seclusion is not an initial assignment, and a
roommate would be overstimulating.
4. A nurse is caring for a client who has severe manifestations of
schizophrenia and is medicated PRN for agitation with haloperidol. The nurse
should assess the client for which of the following adverse effects?
A. Dysrhythmias
B. Cataracts
C. Pancreatitis
D. Bleeding
The Correct Answer Is A. 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 baseline and follow-up ECG
monitoring. The other options are not typically associated with haloperidol use.
5. A nurse on a mental health unit is caring for a client who has generalized
anxiety disorder. The client received a telephone call that was upsetting, and
now the client is pacing up and down the corridors of the unit. Which of the
Ascorers
, following actions should the nurse take?
A. Instruct the client to sit down and stop pacing.
B. Allow the client to pace alone until physically tired.
C. Have a staff member escort the client to her room.
D. Walk with the client at a gradually slower pace.
The Correct Answer Is D. This intervention provides a therapeutic presence and
uses a non-verbal cue to help the client lower her anxiety level. By walking with
her and gradually slowing the pace, the nurse helps the client modulate her own
energy and anxiety in a supportive, non-confrontational way.
6. A nurse is providing discharge teaching to a client who has bipolar disorder
and will be discharged with a prescription for lithium. The nurse should teach
the client that which of the following factors puts her at risk for lithium
toxicity?
A. The client runs 4 miles outdoors every afternoon.
B. The client drinks 2 liters of liquids daily.
C. The client eats 2 to 3 gm of sodium-containing foods daily.
D. The client eats foods high in tyramine.
The Correct Answer Is A. Strenuous exercise leading to significant diaphoresis
(sweating) can cause fluid and sodium loss. Since lithium is a salt, the kidneys may
reabsorb it along with sodium when sodium levels are low, leading to increased
serum lithium levels and potential toxicity. Maintaining consistent fluid and
sodium intake is crucial.
7. A nurse is caring for a client who has major depressive disorder and was
prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago.
The client reports having an improved appetite, but still feels very depressed
and is still having trouble sleeping. Which of the following actions should the
Ascorers
, NUR 253 Exam 2: Mental Health Nursing Concepts
1. A nurse is caring for a client who is dying. The client says, "My mother died
in the hospital, but I did not get there before she died." Which of the following
statements should the nurse make?
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."
The Correct Answer Is B. This response uses the therapeutic technique of
exploring feelings. It acknowledges the client's implied fear and opens the door for
further discussion about their emotions regarding dying alone. The other options
offer false reassurance, make promises that cannot be kept, or avoid addressing the
client's emotional needs.
2. A nurse is caring for a young adult client who says he is experiencing
increased anxiety and an inability to concentrate. Which of the following
responses 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?"
The Correct Answer Is D. 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.
Ascorers
,3. A nurse is admitting a client who is in the manic phase of bipolar disorder.
The nurse should plan to make which of the following room assignments for
the 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.
The Correct Answer Is C. 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 their mania. Seclusion is not an initial assignment, and a
roommate would be overstimulating.
4. A nurse is caring for a client who has severe manifestations of
schizophrenia and is medicated PRN for agitation with haloperidol. The nurse
should assess the client for which of the following adverse effects?
A. Dysrhythmias
B. Cataracts
C. Pancreatitis
D. Bleeding
The Correct Answer Is A. 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 baseline and follow-up ECG
monitoring. The other options are not typically associated with haloperidol use.
5. A nurse on a mental health unit is caring for a client who has generalized
anxiety disorder. The client received a telephone call that was upsetting, and
now the client is pacing up and down the corridors of the unit. Which of the
Ascorers
, following actions should the nurse take?
A. Instruct the client to sit down and stop pacing.
B. Allow the client to pace alone until physically tired.
C. Have a staff member escort the client to her room.
D. Walk with the client at a gradually slower pace.
The Correct Answer Is D. This intervention provides a therapeutic presence and
uses a non-verbal cue to help the client lower her anxiety level. By walking with
her and gradually slowing the pace, the nurse helps the client modulate her own
energy and anxiety in a supportive, non-confrontational way.
6. A nurse is providing discharge teaching to a client who has bipolar disorder
and will be discharged with a prescription for lithium. The nurse should teach
the client that which of the following factors puts her at risk for lithium
toxicity?
A. The client runs 4 miles outdoors every afternoon.
B. The client drinks 2 liters of liquids daily.
C. The client eats 2 to 3 gm of sodium-containing foods daily.
D. The client eats foods high in tyramine.
The Correct Answer Is A. Strenuous exercise leading to significant diaphoresis
(sweating) can cause fluid and sodium loss. Since lithium is a salt, the kidneys may
reabsorb it along with sodium when sodium levels are low, leading to increased
serum lithium levels and potential toxicity. Maintaining consistent fluid and
sodium intake is crucial.
7. A nurse is caring for a client who has major depressive disorder and was
prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago.
The client reports having an improved appetite, but still feels very depressed
and is still having trouble sleeping. Which of the following actions should the
Ascorers
