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Exam (elaborations)

NUR2459 Final Exam Actual Exam Style V1 | NUR 2459 Mental and Behavioral Health Nursing | Rasmussen

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NUR2459 Final Exam Actual Exam Style V1 | NUR 2459 Mental and Behavioral Health Nursing | Rasmussen

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NUR2459 Final Exam Actual Exam Style V1
| NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client who states, ‘I feel like my life is falling apart and there is no

hope.’ Which response by the nurse is therapeutic?

A. ‘Why do you think your life is falling apart right now?’


B. ‘It sounds like you are feeling very overwhelmed and discouraged.’


C. ‘Everything will get better once the medication starts working.’


D. ‘You should focus on the positive things you still have.’


Correct Answer: B


Expert Explanation: This response uses the therapeutic technique of reflection and

validation of the client’s feelings. It avoids asking ‘why’ questions which can put the client

on the defensive. By acknowledging the client’s emotions, the nurse fosters a trusting

relationship and encourages further expression.


2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which

instruction should the nurse include in the teaching?

A. Limit your fluid intake to 1 liter per day.


B. Take the medication only when you feel manic.


C. Maintain a consistent intake of dietary sodium.

,D. Stop taking the medication if you feel fine.


Correct Answer: C


Expert Explanation: Lithium is a salt, and its excretion is closely tied to sodium levels in

the body. If sodium levels drop, the body retains lithium, which can lead to toxicity.

Maintaining a consistent sodium and fluid intake is vital for therapeutic stability.


3. A nurse is assessing a client for suspected alcohol withdrawal. Which of the following is an

early sign of withdrawal?

A. Fine tremors of the hands


B. Profound hypotension


C. Increased appetite


D. Somnolence and bradycardia


Correct Answer: A


Expert Explanation: Early signs of alcohol withdrawal typically include tremors,

diaphoresis, and tachycardia. These symptoms usually manifest within 6 to 12 hours after

the last drink. Identifying these early signs is crucial for preventing progression to delirium

tremens.


4. A client with schizophrenia is experiencing auditory hallucinations. What is the priority

nursing intervention?

A. Leave the client alone to rest in a quiet room.

, B. Tell the client that the voices are not real.


C. Ask the client what the voices are saying.


D. Argue with the client about the reality of the voices.


Correct Answer: C


Expert Explanation: The nurse must determine the content of the hallucinations to assess

for safety, specifically command hallucinations. Command hallucinations may instruct the

client to harm themselves or others. Safety is always the priority in psychiatric nursing

care.


5. Which legal principle refers to the nurse’s obligation to tell the truth?

A. Autonomy


B. Veracity


C. Beneficence


D. Justice


Correct Answer: B


Expert Explanation: Veracity is the ethical principle that requires healthcare providers to

be honest and truthful. This builds trust between the patient and the healthcare team. It is

essential for obtaining informed consent and maintaining professional integrity.

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