NSG 322/NSG322 Final Exam V1 |
Behavioral Health Nursing Q&A with
Rationale | Grand Canyon University
1. A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. The
client is moving rapidly around the unit, talking loudly and interrupting others. Which of the
following interventions is the priority?
A. Setting clear limits on the client’s behavior.
B. Providing high-calorie finger foods for the client.
C. Encouraging the client to join a group therapy session.
D. Administering a prescribed PRN sedative immediately.
Answer: B
Rationale: Clients in a manic state often have excessive physical activity and are unable to
sit down to eat. Providing high-calorie finger foods allows the client to maintain nutritional
intake while on the move, addressing a physiological need. While setting limits is important
for safety, meeting nutritional requirements is a priority to prevent exhaustion and
physical decline in this hyperactive state.
2. A client is prescribed Lithium Carbonate for the treatment of bipolar disorder. The nurse
should instruct the client to monitor for which of the following signs of early lithium toxicity?
A. Nausea, vomiting, and fine hand tremors.
,B. Coarse hand tremors and ataxia.
C. Seizures and severe hypotension.
D. Constipation and blurred vision.
Answer: A
Rationale: Early signs of lithium toxicity occur at levels between 1.5 to 2.0 mEq/L and
typically involve gastrointestinal upset and fine tremors. The nurse must educate the client
to stop the medication and contact the provider if these symptoms occur to prevent
progression. Coarse tremors and ataxia are signs of advanced toxicity, which is more severe
and requires immediate medical intervention.
3. A nurse is performing an admission assessment on a client with schizophrenia who is
experiencing auditory hallucinations. What is the most important question for the nurse to
ask?
A. “How long have you been hearing these voices?”
B. “Do you understand that the voices are not real?”
C. “Do you recognize the voices you are hearing?”
D. “What are the voices telling you to do?”
Answer: D
Rationale: Safety is the priority when assessing hallucinations, especially command
hallucinations where the client may be told to harm themselves or others. Identifying the
,content of the hallucination allows the nurse to implement necessary safety precautions. It
is essential to determine if the client feels compelled to follow the commands provided by
the voices.
4. Which of the following defense mechanisms is a client using when they state, ‘I only drink
because my wife nags me all the time’?
A. Projection
B. Reaction Formation
C. Displacement
D. Rationalization
Answer: D
Rationale: Rationalization involves justifying illogical or unreasonable ideas or feelings by
developing acceptable explanations that satisfy the teller and the listener. In this case, the
client is attempting to make their behavior seem reasonable by blaming an external factor.
This mechanism helps the individual protect their self-esteem and avoid dealing with the
reality of their addiction.
5. A client with Major Depressive Disorder is being started on Phenelzine (Nardil). Which food
choice on the client’s meal tray should the nurse intervene on?
A. Fresh grilled chicken breast
B. Aged cheddar cheese and crackers
C. Steamed broccoli and carrots
, D. White rice and apple slices
Answer: B
Rationale: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that interacts
dangerously with tyramine-rich foods. Aged cheeses, fermented meats, and certain wines
can cause a hypertensive crisis when consumed with MAOIs. The nurse must provide
extensive education to the client about a low-tyramine diet to ensure their safety during
treatment.
6. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which clinical
finding would support this diagnosis?
A. Hypothermia and bradycardia
B. Muscle flaccidity and diarrhea
C. Severe muscle rigidity and hyperpyrexia
D. Hyperreflexia and agitation
Answer: C
Rationale: Neuroleptic Malignant Syndrome is a life-threatening emergency characterized
by lead-pipe muscle rigidity, high fever (hyperpyrexia), and autonomic instability. It is
usually caused by an adverse reaction to antipsychotic medications. Immediate
discontinuation of the drug and supportive care in an intensive care unit are required for
the patient’s survival.
Behavioral Health Nursing Q&A with
Rationale | Grand Canyon University
1. A nurse is caring for a client with bipolar disorder who is experiencing a manic episode. The
client is moving rapidly around the unit, talking loudly and interrupting others. Which of the
following interventions is the priority?
A. Setting clear limits on the client’s behavior.
B. Providing high-calorie finger foods for the client.
C. Encouraging the client to join a group therapy session.
D. Administering a prescribed PRN sedative immediately.
Answer: B
Rationale: Clients in a manic state often have excessive physical activity and are unable to
sit down to eat. Providing high-calorie finger foods allows the client to maintain nutritional
intake while on the move, addressing a physiological need. While setting limits is important
for safety, meeting nutritional requirements is a priority to prevent exhaustion and
physical decline in this hyperactive state.
2. A client is prescribed Lithium Carbonate for the treatment of bipolar disorder. The nurse
should instruct the client to monitor for which of the following signs of early lithium toxicity?
A. Nausea, vomiting, and fine hand tremors.
,B. Coarse hand tremors and ataxia.
C. Seizures and severe hypotension.
D. Constipation and blurred vision.
Answer: A
Rationale: Early signs of lithium toxicity occur at levels between 1.5 to 2.0 mEq/L and
typically involve gastrointestinal upset and fine tremors. The nurse must educate the client
to stop the medication and contact the provider if these symptoms occur to prevent
progression. Coarse tremors and ataxia are signs of advanced toxicity, which is more severe
and requires immediate medical intervention.
3. A nurse is performing an admission assessment on a client with schizophrenia who is
experiencing auditory hallucinations. What is the most important question for the nurse to
ask?
A. “How long have you been hearing these voices?”
B. “Do you understand that the voices are not real?”
C. “Do you recognize the voices you are hearing?”
D. “What are the voices telling you to do?”
Answer: D
Rationale: Safety is the priority when assessing hallucinations, especially command
hallucinations where the client may be told to harm themselves or others. Identifying the
,content of the hallucination allows the nurse to implement necessary safety precautions. It
is essential to determine if the client feels compelled to follow the commands provided by
the voices.
4. Which of the following defense mechanisms is a client using when they state, ‘I only drink
because my wife nags me all the time’?
A. Projection
B. Reaction Formation
C. Displacement
D. Rationalization
Answer: D
Rationale: Rationalization involves justifying illogical or unreasonable ideas or feelings by
developing acceptable explanations that satisfy the teller and the listener. In this case, the
client is attempting to make their behavior seem reasonable by blaming an external factor.
This mechanism helps the individual protect their self-esteem and avoid dealing with the
reality of their addiction.
5. A client with Major Depressive Disorder is being started on Phenelzine (Nardil). Which food
choice on the client’s meal tray should the nurse intervene on?
A. Fresh grilled chicken breast
B. Aged cheddar cheese and crackers
C. Steamed broccoli and carrots
, D. White rice and apple slices
Answer: B
Rationale: Phenelzine is a Monoamine Oxidase Inhibitor (MAOI) that interacts
dangerously with tyramine-rich foods. Aged cheeses, fermented meats, and certain wines
can cause a hypertensive crisis when consumed with MAOIs. The nurse must provide
extensive education to the client about a low-tyramine diet to ensure their safety during
treatment.
6. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which clinical
finding would support this diagnosis?
A. Hypothermia and bradycardia
B. Muscle flaccidity and diarrhea
C. Severe muscle rigidity and hyperpyrexia
D. Hyperreflexia and agitation
Answer: C
Rationale: Neuroleptic Malignant Syndrome is a life-threatening emergency characterized
by lead-pipe muscle rigidity, high fever (hyperpyrexia), and autonomic instability. It is
usually caused by an adverse reaction to antipsychotic medications. Immediate
discontinuation of the drug and supportive care in an intensive care unit are required for
the patient’s survival.
