NUR 2459 Final Exam Actual Exam V1 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A client with bipolar disorder is in the manic phase and is moving rapidly around the unit,
interrupting others and shouting. Which nursing intervention is the priority?
A. Escort the client to a quiet area with low stimulation.
B. Administer an extra dose of oral lithium immediately.
C. Ask the client to explain why they are feeling so energetic.
D. Gather other clients for a group discussion about the behavior.
Answer: A
Rationale: Safety and stabilization are the priorities during an acute manic episode.
Reducing environmental stimuli helps decrease the client’s hyperactivity and prevents
escalation. This intervention also protects other clients from the disruptive behavior while
maintaining the client’s dignity.
2. A nurse is caring for a client starting clozapine for treatment-resistant schizophrenia. Which
laboratory result must the nurse monitor most closely?
A. Serum potassium levels
B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Liver function tests (LFTs)
Answer: C
Rationale: Clozapine carries a significant risk for agranulocytosis, which is a life-
threatening decrease in white blood cells. Baseline and weekly monitoring of the Absolute
Neutrophil Count (ANC) is mandatory to prevent severe infection. If the WBC count falls
below a certain threshold, the medication must be discontinued immediately.
3. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which statement by the client indicates the highest risk for suicide?
A. I just don’t feel like doing anything anymore.
B. I’ve been having some thoughts that my family would be better off without me.
C. I wish I could just sleep for a very long time.
D. I have a plan to use the gun in my garage tomorrow while my wife is at work.
Answer: D
,Rationale: A specific plan with a lethal method and a designated time indicates a high level
of suicidal intent. Assessing the lethality and availability of the method is a critical step in
suicide risk assessment. The nurse must implement immediate one-to-one observation for
this client.
4. A nurse is using therapeutic communication with a client who is distressed. The client says,
‘My husband is always angry at me.’ Which response by the nurse is therapeutic?
A. Why do you think he is angry with you?
B. You should try to talk to him when he is calm.
C. It sounds like you are feeling overwhelmed by your husband’s anger.
D. Don’t worry, most marriages have these kinds of problems.
Answer: C
Rationale: Reflecting the client’s feelings is a therapeutic technique that validates the
client’s experience. Using ‘why’ questions can be perceived as accusatory or defensive and
should be avoided. Offering advice or false reassurance shuts down further communication
and minimizes the client’s feelings.
5. A client with schizophrenia is experiencing auditory hallucinations. What is the most
appropriate initial nursing action?
A. Tell the client that the voices are not real.
B. Turn up the radio to drown out the voices.
C. Ask the client what the voices are saying.
D. Leave the client alone so they can process the voices.
Answer: C
Rationale: The nurse must assess the content of the hallucinations to determine if they are
‘command’ hallucinations that might instruct the client to harm themselves or others.
While the nurse should not reinforce the hallucination, they must acknowledge the client’s
experience. Safety is the primary concern when hallucinations are present.
6. A nurse is teaching a client about a new prescription for phenelzine, an MAOI. Which food
choice by the client indicates a need for further teaching?
A. Fresh chicken breast
B. Green leafy vegetables
C. Aged cheddar cheese
D. Apples and oranges
Answer: C
, Rationale: Aged cheeses are high in tyramine, which can cause a hypertensive crisis when
consumed by a client taking an MAOI. Clients must be taught to avoid aged, cured,
fermented, or smoked foods. This dietary restriction is vital for preventing life-threatening
elevations in blood pressure.
7. A client has been prescribed lithium for bipolar disorder. The nurse notes the client has a
serum lithium level of 1.8 mEq/L. What is the nurse’s priority action?
A. Administer the next scheduled dose as ordered.
B. Withhold the medication and notify the provider.
C. Request an increase in the client’s fluid intake.
D. Re-draw the lithium level to confirm the result.
Answer: B
Rationale: The therapeutic range for lithium is 0.6 to 1.2 mEq/L; a level of 1.8 mEq/L
indicates moderate toxicity. Symptoms of toxicity can include coarse tremors, GI upset, and
mental confusion. The nurse must withhold the dose and seek medical intervention to
prevent further escalation of toxicity.
8. A nurse is assessing a client for alcohol withdrawal. Which symptoms are expected during
the first 6 to 12 hours after the last drink?
A. Severe auditory hallucinations and seizures
B. Tremors, tachycardia, and anxiety
C. Deep sleep and bradycardia
D. Delirium tremens and fever
Answer: B
Rationale: Early symptoms of alcohol withdrawal typically include tremors, sweating,
elevated heart rate, and restlessness. Delirium tremens and seizures are late-stage, more
severe withdrawal complications. Monitoring the client with the CIWA-Ar scale helps track
these early symptoms to guide treatment.
9. A client with Borderline Personality Disorder (BPD) tells the day-shift nurse, ‘The night
nurse is so mean, but you are the best nurse ever.’ The nurse recognizes this as which defense
mechanism?
A. Reaction formation
B. Splitting
C. Projection
D. Rationalization
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A client with bipolar disorder is in the manic phase and is moving rapidly around the unit,
interrupting others and shouting. Which nursing intervention is the priority?
A. Escort the client to a quiet area with low stimulation.
B. Administer an extra dose of oral lithium immediately.
C. Ask the client to explain why they are feeling so energetic.
D. Gather other clients for a group discussion about the behavior.
Answer: A
Rationale: Safety and stabilization are the priorities during an acute manic episode.
Reducing environmental stimuli helps decrease the client’s hyperactivity and prevents
escalation. This intervention also protects other clients from the disruptive behavior while
maintaining the client’s dignity.
2. A nurse is caring for a client starting clozapine for treatment-resistant schizophrenia. Which
laboratory result must the nurse monitor most closely?
A. Serum potassium levels
B. Blood urea nitrogen (BUN)
C. White blood cell (WBC) count
D. Liver function tests (LFTs)
Answer: C
Rationale: Clozapine carries a significant risk for agranulocytosis, which is a life-
threatening decrease in white blood cells. Baseline and weekly monitoring of the Absolute
Neutrophil Count (ANC) is mandatory to prevent severe infection. If the WBC count falls
below a certain threshold, the medication must be discontinued immediately.
3. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which statement by the client indicates the highest risk for suicide?
A. I just don’t feel like doing anything anymore.
B. I’ve been having some thoughts that my family would be better off without me.
C. I wish I could just sleep for a very long time.
D. I have a plan to use the gun in my garage tomorrow while my wife is at work.
Answer: D
,Rationale: A specific plan with a lethal method and a designated time indicates a high level
of suicidal intent. Assessing the lethality and availability of the method is a critical step in
suicide risk assessment. The nurse must implement immediate one-to-one observation for
this client.
4. A nurse is using therapeutic communication with a client who is distressed. The client says,
‘My husband is always angry at me.’ Which response by the nurse is therapeutic?
A. Why do you think he is angry with you?
B. You should try to talk to him when he is calm.
C. It sounds like you are feeling overwhelmed by your husband’s anger.
D. Don’t worry, most marriages have these kinds of problems.
Answer: C
Rationale: Reflecting the client’s feelings is a therapeutic technique that validates the
client’s experience. Using ‘why’ questions can be perceived as accusatory or defensive and
should be avoided. Offering advice or false reassurance shuts down further communication
and minimizes the client’s feelings.
5. A client with schizophrenia is experiencing auditory hallucinations. What is the most
appropriate initial nursing action?
A. Tell the client that the voices are not real.
B. Turn up the radio to drown out the voices.
C. Ask the client what the voices are saying.
D. Leave the client alone so they can process the voices.
Answer: C
Rationale: The nurse must assess the content of the hallucinations to determine if they are
‘command’ hallucinations that might instruct the client to harm themselves or others.
While the nurse should not reinforce the hallucination, they must acknowledge the client’s
experience. Safety is the primary concern when hallucinations are present.
6. A nurse is teaching a client about a new prescription for phenelzine, an MAOI. Which food
choice by the client indicates a need for further teaching?
A. Fresh chicken breast
B. Green leafy vegetables
C. Aged cheddar cheese
D. Apples and oranges
Answer: C
, Rationale: Aged cheeses are high in tyramine, which can cause a hypertensive crisis when
consumed by a client taking an MAOI. Clients must be taught to avoid aged, cured,
fermented, or smoked foods. This dietary restriction is vital for preventing life-threatening
elevations in blood pressure.
7. A client has been prescribed lithium for bipolar disorder. The nurse notes the client has a
serum lithium level of 1.8 mEq/L. What is the nurse’s priority action?
A. Administer the next scheduled dose as ordered.
B. Withhold the medication and notify the provider.
C. Request an increase in the client’s fluid intake.
D. Re-draw the lithium level to confirm the result.
Answer: B
Rationale: The therapeutic range for lithium is 0.6 to 1.2 mEq/L; a level of 1.8 mEq/L
indicates moderate toxicity. Symptoms of toxicity can include coarse tremors, GI upset, and
mental confusion. The nurse must withhold the dose and seek medical intervention to
prevent further escalation of toxicity.
8. A nurse is assessing a client for alcohol withdrawal. Which symptoms are expected during
the first 6 to 12 hours after the last drink?
A. Severe auditory hallucinations and seizures
B. Tremors, tachycardia, and anxiety
C. Deep sleep and bradycardia
D. Delirium tremens and fever
Answer: B
Rationale: Early symptoms of alcohol withdrawal typically include tremors, sweating,
elevated heart rate, and restlessness. Delirium tremens and seizures are late-stage, more
severe withdrawal complications. Monitoring the client with the CIWA-Ar scale helps track
these early symptoms to guide treatment.
9. A client with Borderline Personality Disorder (BPD) tells the day-shift nurse, ‘The night
nurse is so mean, but you are the best nurse ever.’ The nurse recognizes this as which defense
mechanism?
A. Reaction formation
B. Splitting
C. Projection
D. Rationalization
