NSG 322/NSG322 Exam 2 V2 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
Which meal choice is most appropriate for this client?
A. Spaghetti and meatballs with a side salad
B. Beef stew with a dinner roll
C. Chicken nuggets and an apple
D. Baked fish with mashed potatoes
Correct Answer: C
Expert Explanation: Clients in a manic phase often have high energy and difficulty sitting
still for long periods. Providing high-calorie finger foods allows the client to eat while
moving, ensuring adequate nutritional intake. This intervention addresses the safety and
physiological needs of a patient who cannot focus on using utensils.
,2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Potassium
B. Serum Calcium
C. Serum Sodium
D. Serum Magnesium
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. When sodium levels are low, the kidneys retain lithium, leading to potentially
toxic levels. The nurse must educate the client on maintaining a consistent sodium intake
and staying hydrated.
3. A client diagnosed with Schizophrenia tells the nurse, ‘The FBI is tracking my every move
through the television.’ How should the nurse respond?
A. That is impossible; the FBI does not have that technology.
B. I don’t see any evidence of that, but it must be frightening to feel that way.
C. Why do you think the FBI is interested in you?
D. Let’s turn off the TV so they can’t see you anymore.
Correct Answer: B
Expert Explanation: This response acknowledges the client’s feelings without validating
the delusion or arguing with the client. It is important to focus on the underlying emotion
, (fear) rather than the content of the delusion. Presenting reality gently helps build trust
without causing the client to become defensive.
4. Which assessment finding is a priority for a nurse caring for a client starting Clozapine?
A. Weight gain of 2 lbs in one week
B. White blood cell (WBC) count of 2,500/mm3
C. Increased salivation during sleep
D. Dizziness upon standing
Correct Answer: B
Expert Explanation: Clozapine carries a high risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. A WBC count below 3,000/mm3 requires
immediate discontinuation of the medication and medical intervention. Monitoring blood
counts is a mandatory safety protocol for any patient on this atypical antipsychotic.
5. A nurse is assessing a client for Serotonin Syndrome. which set of symptoms should the
nurse look for?
A. Hypothermia, bradycardia, and constipation
B. Hyperreflexia, tremors, and diaphoresis
C. Dry mouth, blurred vision, and urinary retention
D. Extreme lethargy, hypotension, and skin rash
Correct Answer: B
Expert Explanation: Serotonin Syndrome is a potentially fatal reaction characterized by
mental status changes, neuromuscular hyperactivity, and autonomic instability.
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing a manic episode.
Which meal choice is most appropriate for this client?
A. Spaghetti and meatballs with a side salad
B. Beef stew with a dinner roll
C. Chicken nuggets and an apple
D. Baked fish with mashed potatoes
Correct Answer: C
Expert Explanation: Clients in a manic phase often have high energy and difficulty sitting
still for long periods. Providing high-calorie finger foods allows the client to eat while
moving, ensuring adequate nutritional intake. This intervention addresses the safety and
physiological needs of a patient who cannot focus on using utensils.
,2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Potassium
B. Serum Calcium
C. Serum Sodium
D. Serum Magnesium
Correct Answer: C
Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in
the body. When sodium levels are low, the kidneys retain lithium, leading to potentially
toxic levels. The nurse must educate the client on maintaining a consistent sodium intake
and staying hydrated.
3. A client diagnosed with Schizophrenia tells the nurse, ‘The FBI is tracking my every move
through the television.’ How should the nurse respond?
A. That is impossible; the FBI does not have that technology.
B. I don’t see any evidence of that, but it must be frightening to feel that way.
C. Why do you think the FBI is interested in you?
D. Let’s turn off the TV so they can’t see you anymore.
Correct Answer: B
Expert Explanation: This response acknowledges the client’s feelings without validating
the delusion or arguing with the client. It is important to focus on the underlying emotion
, (fear) rather than the content of the delusion. Presenting reality gently helps build trust
without causing the client to become defensive.
4. Which assessment finding is a priority for a nurse caring for a client starting Clozapine?
A. Weight gain of 2 lbs in one week
B. White blood cell (WBC) count of 2,500/mm3
C. Increased salivation during sleep
D. Dizziness upon standing
Correct Answer: B
Expert Explanation: Clozapine carries a high risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. A WBC count below 3,000/mm3 requires
immediate discontinuation of the medication and medical intervention. Monitoring blood
counts is a mandatory safety protocol for any patient on this atypical antipsychotic.
5. A nurse is assessing a client for Serotonin Syndrome. which set of symptoms should the
nurse look for?
A. Hypothermia, bradycardia, and constipation
B. Hyperreflexia, tremors, and diaphoresis
C. Dry mouth, blurred vision, and urinary retention
D. Extreme lethargy, hypotension, and skin rash
Correct Answer: B
Expert Explanation: Serotonin Syndrome is a potentially fatal reaction characterized by
mental status changes, neuromuscular hyperactivity, and autonomic instability.
