NUR 2459 Final Exam Actual Exam V2 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which statement by the nurse demonstrates effective therapeutic communication during the
initial assessment?
A. “Why do you feel so sad all the time?”
B. “I know exactly how you feel; I have been sad before too.”
C. “Tell me more about the things that have been bothering you lately.”
D. “You should try to participate in group activities to feel better.”
Answer: C
Rationale: Open-ended questions allow the client to lead the conversation and express
their feelings without being restricted by yes or no answers. This technique encourages the
client to elaborate on their experiences, which is vital for a thorough assessment. It also
avoids ‘why’ questions, which can make a client feel defensive and shut down
communication.
2. A nurse is caring for a client who is experiencing a panic attack. Which intervention should
the nurse implement first?
A. Teach the client how to use guided imagery.
B. Stay with the client and use short, simple sentences.
C. Administer an as-needed (PRN) dose of an antidepressant.
D. Encourage the client to discuss the source of their anxiety.
Answer: B
Rationale: The nurse’s primary responsibility during a panic attack is to ensure the client’s
safety and provide a calming presence. Using short, simple sentences is necessary because
the client’s ability to process information is severely limited during periods of high anxiety.
Staying with the client prevents them from feeling abandoned and helps decrease the
intensity of the panic.
3. A client diagnosed with Bipolar I Disorder is in the manic phase and is moving rapidly
around the unit, talking loudly and interrupting others. Which of the following is the most
appropriate action by the nurse?
A. Place the client in seclusion to prevent overstimulation.
B. Ask the client to lead a group discussion to channel energy.
,C. Instruct the client to sit still for 30 minutes in the dayroom.
D. Provide the client with high-calorie finger foods.
Answer: D
Rationale: Clients in a manic phase often have excessive energy and cannot sit down long
enough to eat a full meal, putting them at risk for nutritional deficits. High-calorie finger
foods allow the client to consume necessary nutrients while on the move. This intervention
addresses the physiological need for energy and hydration during a period of hyperactivity.
4. A nurse is assessing a client for potential Lithium toxicity. Which of the following findings
should the nurse report to the provider immediately?
A. Fine hand tremors and mild thirst.
B. Coarse tremors, confusion, and ataxia.
C. Polyuria and a slight metallic taste in the mouth.
D. Weight gain of 2 pounds in one month.
Answer: B
Rationale: Coarse tremors, confusion, and ataxia are significant indicators of advanced
Lithium toxicity, which can be life-threatening if not treated. Fine tremors and mild thirst
are common side effects that often occur at therapeutic levels. Immediate reporting and
intervention are required to prevent permanent neurological damage or death from severe
toxicity.
5. A client who has been taking Haloperidol for several years exhibits involuntary tongue
protrusion and lip-smacking. The nurse recognizes these symptoms as which of the following?
A. Akathisia
B. Pseudoparkinsonism
C. Tardive Dyskinesia
D. Neuroleptic Malignant Syndrome
Answer: C
Rationale: Tardive Dyskinesia is a late-onset extrapyramidal side effect characterized by
repetitive, involuntary movements such as grimacing and tongue protrusion. It is often
irreversible if the causative antipsychotic medication is not discontinued or adjusted. The
nurse must monitor clients on long-term antipsychotics closely using the Abnormal
Involuntary Movement Scale (AIMS).
6. Which of the following dietary choices should a client avoid while taking a Monoamine
Oxidase Inhibitor (MAOI) for depression?
A. Aged cheddar cheese and pepperoni pizza.
, B. Grilled chicken breast and white rice.
C. Fresh green leafy vegetables and apples.
D. Orange juice and whole-wheat toast.
Answer: A
Rationale: MAOIs interact with tyramine-rich foods, which can trigger a hypertensive
crisis. Aged cheeses and processed meats like pepperoni contain high levels of tyramine
and must be strictly avoided. Education on a low-tyramine diet is a critical component of
nursing care for clients prescribed these medications.
7. A client is admitted to the hospital for alcohol detoxification. Which of the following
medications should the nurse expect to administer to manage acute withdrawal symptoms?
A. Chlordiazepoxide
B. Disulfiram
C. Methadone
D. Varenicline
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent seizures and stabilize
vital signs during acute alcohol withdrawal. It works by enhancing the effect of the
neurotransmitter GABA to calm the central nervous system. This medication is essential for
preventing the progression of withdrawal to delirium tremens.
8. A nurse is caring for a client with Schizophrenia who is experiencing auditory
hallucinations. The client says, ‘The voices are telling me I am a bad person.’ Which response
by the nurse is therapeutic?
A. “You know those voices aren’t real; it’s just your illness.”
B. “What exactly are the voices telling you to do right now?”
C. “I don’t hear the voices, but I understand they are real to you.”
D. “Try to ignore the voices and focus on the television.”
Answer: C
Rationale: This response validates the client’s experience without agreeing with the
hallucination, a technique known as presenting reality. It shows empathy while
maintaining the nurse’s perspective as a stable, reality-based figure. Identifying the content
of the voices (option B) is also important if there is a risk of command hallucinations, but
option A is the best initial therapeutic response.
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which statement by the nurse demonstrates effective therapeutic communication during the
initial assessment?
A. “Why do you feel so sad all the time?”
B. “I know exactly how you feel; I have been sad before too.”
C. “Tell me more about the things that have been bothering you lately.”
D. “You should try to participate in group activities to feel better.”
Answer: C
Rationale: Open-ended questions allow the client to lead the conversation and express
their feelings without being restricted by yes or no answers. This technique encourages the
client to elaborate on their experiences, which is vital for a thorough assessment. It also
avoids ‘why’ questions, which can make a client feel defensive and shut down
communication.
2. A nurse is caring for a client who is experiencing a panic attack. Which intervention should
the nurse implement first?
A. Teach the client how to use guided imagery.
B. Stay with the client and use short, simple sentences.
C. Administer an as-needed (PRN) dose of an antidepressant.
D. Encourage the client to discuss the source of their anxiety.
Answer: B
Rationale: The nurse’s primary responsibility during a panic attack is to ensure the client’s
safety and provide a calming presence. Using short, simple sentences is necessary because
the client’s ability to process information is severely limited during periods of high anxiety.
Staying with the client prevents them from feeling abandoned and helps decrease the
intensity of the panic.
3. A client diagnosed with Bipolar I Disorder is in the manic phase and is moving rapidly
around the unit, talking loudly and interrupting others. Which of the following is the most
appropriate action by the nurse?
A. Place the client in seclusion to prevent overstimulation.
B. Ask the client to lead a group discussion to channel energy.
,C. Instruct the client to sit still for 30 minutes in the dayroom.
D. Provide the client with high-calorie finger foods.
Answer: D
Rationale: Clients in a manic phase often have excessive energy and cannot sit down long
enough to eat a full meal, putting them at risk for nutritional deficits. High-calorie finger
foods allow the client to consume necessary nutrients while on the move. This intervention
addresses the physiological need for energy and hydration during a period of hyperactivity.
4. A nurse is assessing a client for potential Lithium toxicity. Which of the following findings
should the nurse report to the provider immediately?
A. Fine hand tremors and mild thirst.
B. Coarse tremors, confusion, and ataxia.
C. Polyuria and a slight metallic taste in the mouth.
D. Weight gain of 2 pounds in one month.
Answer: B
Rationale: Coarse tremors, confusion, and ataxia are significant indicators of advanced
Lithium toxicity, which can be life-threatening if not treated. Fine tremors and mild thirst
are common side effects that often occur at therapeutic levels. Immediate reporting and
intervention are required to prevent permanent neurological damage or death from severe
toxicity.
5. A client who has been taking Haloperidol for several years exhibits involuntary tongue
protrusion and lip-smacking. The nurse recognizes these symptoms as which of the following?
A. Akathisia
B. Pseudoparkinsonism
C. Tardive Dyskinesia
D. Neuroleptic Malignant Syndrome
Answer: C
Rationale: Tardive Dyskinesia is a late-onset extrapyramidal side effect characterized by
repetitive, involuntary movements such as grimacing and tongue protrusion. It is often
irreversible if the causative antipsychotic medication is not discontinued or adjusted. The
nurse must monitor clients on long-term antipsychotics closely using the Abnormal
Involuntary Movement Scale (AIMS).
6. Which of the following dietary choices should a client avoid while taking a Monoamine
Oxidase Inhibitor (MAOI) for depression?
A. Aged cheddar cheese and pepperoni pizza.
, B. Grilled chicken breast and white rice.
C. Fresh green leafy vegetables and apples.
D. Orange juice and whole-wheat toast.
Answer: A
Rationale: MAOIs interact with tyramine-rich foods, which can trigger a hypertensive
crisis. Aged cheeses and processed meats like pepperoni contain high levels of tyramine
and must be strictly avoided. Education on a low-tyramine diet is a critical component of
nursing care for clients prescribed these medications.
7. A client is admitted to the hospital for alcohol detoxification. Which of the following
medications should the nurse expect to administer to manage acute withdrawal symptoms?
A. Chlordiazepoxide
B. Disulfiram
C. Methadone
D. Varenicline
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent seizures and stabilize
vital signs during acute alcohol withdrawal. It works by enhancing the effect of the
neurotransmitter GABA to calm the central nervous system. This medication is essential for
preventing the progression of withdrawal to delirium tremens.
8. A nurse is caring for a client with Schizophrenia who is experiencing auditory
hallucinations. The client says, ‘The voices are telling me I am a bad person.’ Which response
by the nurse is therapeutic?
A. “You know those voices aren’t real; it’s just your illness.”
B. “What exactly are the voices telling you to do right now?”
C. “I don’t hear the voices, but I understand they are real to you.”
D. “Try to ignore the voices and focus on the television.”
Answer: C
Rationale: This response validates the client’s experience without agreeing with the
hallucination, a technique known as presenting reality. It shows empathy while
maintaining the nurse’s perspective as a stable, reality-based figure. Identifying the content
of the voices (option B) is also important if there is a risk of command hallucinations, but
option A is the best initial therapeutic response.
