NUR2459/NUR 2459 Final Exam V3 |
Mental and Behavioral Health Nursing
Q&A with Rationale | Rasmussen
University
1. A nurse is assessing a client who is experiencing a moderate level of anxiety. Which of the
following findings should the nurse expect?
A. Focused on a specific detail
B. Severe cognitive impairment
C. Experience of terror or horror
D. Perceptual field is slightly narrowed
Answer: D
Rationale: In moderate anxiety, the individual’s perceptual field narrows, and they may
miss some details in their environment. The person can still attend to their surroundings if
directed, though they exhibit selective inattention. This level of anxiety typically involves
increased muscle tension and a slightly faster heart rate.
2. Which laboratory value should the nurse monitor most closely for a client receiving Lithium
Carbonate for Bipolar Disorder?
A. White blood cell count
B. Prothrombin time
,C. Serum sodium levels
D. Blood glucose levels
Answer: C
Rationale: Sodium levels have a significant impact on lithium excretion by the kidneys. If
sodium levels are low, the kidneys retain lithium, which can lead to toxicity. The nurse
must ensure the client maintains a consistent intake of salt and fluids to prevent
complications.
3. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
‘hurt the doctor.’ What is the nurse’s priority action?
A. Ask the client to describe the voices in detail
B. Ask the client what the voices are saying to assess for command hallucinations
C. Provide a quiet environment for the client
D. Administer a PRN sedative immediately
Answer: B
Rationale: Command hallucinations represent a high safety risk as they may direct the
client to harm themselves or others. Identifying the specific instructions given by the voices
is the first step in ensuring a safe environment. Once the risk is assessed, the nurse can
implement appropriate safety precautions and interventions.
, 4. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which side effect
requires immediate notification to the provider?
A. Fever and sore throat
B. Salivation
C. Weight gain
D. Drowsiness
Answer: A
Rationale: Fever and sore throat are potential indicators of agranulocytosis, which is a life-
threatening reduction in white blood cells. Clients taking Clozapine must undergo regular
blood monitoring to detect this condition early. If agranulocytosis is suspected, the
medication must be discontinued immediately to prevent severe infection.
5. Which dietary choice by a client taking Phenelzine (an MAOI) indicates that the client
understands the nutritional restrictions?
A. Grilled chicken sandwich
B. Pepperoni pizza
C. Aged cheddar cheese
D. Red wine and crackers
Answer: A
Mental and Behavioral Health Nursing
Q&A with Rationale | Rasmussen
University
1. A nurse is assessing a client who is experiencing a moderate level of anxiety. Which of the
following findings should the nurse expect?
A. Focused on a specific detail
B. Severe cognitive impairment
C. Experience of terror or horror
D. Perceptual field is slightly narrowed
Answer: D
Rationale: In moderate anxiety, the individual’s perceptual field narrows, and they may
miss some details in their environment. The person can still attend to their surroundings if
directed, though they exhibit selective inattention. This level of anxiety typically involves
increased muscle tension and a slightly faster heart rate.
2. Which laboratory value should the nurse monitor most closely for a client receiving Lithium
Carbonate for Bipolar Disorder?
A. White blood cell count
B. Prothrombin time
,C. Serum sodium levels
D. Blood glucose levels
Answer: C
Rationale: Sodium levels have a significant impact on lithium excretion by the kidneys. If
sodium levels are low, the kidneys retain lithium, which can lead to toxicity. The nurse
must ensure the client maintains a consistent intake of salt and fluids to prevent
complications.
3. A nurse is caring for a client with schizophrenia who reports hearing voices telling them to
‘hurt the doctor.’ What is the nurse’s priority action?
A. Ask the client to describe the voices in detail
B. Ask the client what the voices are saying to assess for command hallucinations
C. Provide a quiet environment for the client
D. Administer a PRN sedative immediately
Answer: B
Rationale: Command hallucinations represent a high safety risk as they may direct the
client to harm themselves or others. Identifying the specific instructions given by the voices
is the first step in ensuring a safe environment. Once the risk is assessed, the nurse can
implement appropriate safety precautions and interventions.
, 4. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which side effect
requires immediate notification to the provider?
A. Fever and sore throat
B. Salivation
C. Weight gain
D. Drowsiness
Answer: A
Rationale: Fever and sore throat are potential indicators of agranulocytosis, which is a life-
threatening reduction in white blood cells. Clients taking Clozapine must undergo regular
blood monitoring to detect this condition early. If agranulocytosis is suspected, the
medication must be discontinued immediately to prevent severe infection.
5. Which dietary choice by a client taking Phenelzine (an MAOI) indicates that the client
understands the nutritional restrictions?
A. Grilled chicken sandwich
B. Pepperoni pizza
C. Aged cheddar cheese
D. Red wine and crackers
Answer: A
