NUR 2459 Exam 2 Actual Exam V3 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client with bipolar disorder is prescribed lithium carbonate. Which laboratory result
should the nurse prioritize for review before administering the next dose?
A. Serum potassium level of 3.8 mEq/L
B. Serum lithium level of 1.8 mEq/L
C. White blood cell count of 8,000/mm3
D. Fast blood glucose of 100 mg/dL
Answer: B
Rationale: A serum lithium level of 1.8 mEq/L indicates toxicity, as the therapeutic range
is generally 0.6 to 1.2 mEq/L. The nurse must hold the dose and notify the provider to
prevent severe complications like seizures or coma. This question tests the nurse’s ability
to prioritize safety based on narrow therapeutic index drug monitoring.
2. A patient in an acute manic phase of bipolar disorder is moving rapidly around the unit,
interrupting others and shouting. Which nursing intervention is most appropriate?
A. Ask the patient to sit in the dayroom and watch a movie
B. Encourage the patient to lead a group exercise session
C. Provide high-calorie finger foods and fluids
D. Place the patient in immediate mechanical restraints
Answer: C
Rationale: Patients in acute mania often cannot sit still long enough to eat a full meal,
leading to nutritional deficits. High-calorie finger foods allow them to eat while moving.
This intervention addresses the physiological integrity of the patient during a period of
hyperactive behavior.
3. A client diagnosed with schizophrenia states, ‘The voices are telling me that the food is
poisoned.’ Which response by the nurse is therapeutic?
A. I don’t hear the voices, but I understand that they are real to you.
B. I don’t hear any voices; you are just having a hallucination.
C. Don’t be silly, the food is fine. I am eating it too.
D. Why do the voices want to poison you?
Answer: A
,Rationale: This response presents reality while validating the client’s feelings without
agreeing with the hallucination. Avoiding ‘why’ questions prevents the client from
becoming defensive or further entrenched in the delusion. This approach builds trust and
maintains a professional therapeutic boundary.
4. A nurse is caring for a client experiencing a panic level of anxiety. Which action should the
nurse take first?
A. Teach the client a new relaxation technique
B. Stay with the client and remain calm
C. Leave the client alone to allow them space to calm down
D. Ask the client to describe what triggered the panic
Answer: B
Rationale: During panic-level anxiety, a person’s safety is the priority because they may
lose touch with reality. Staying with the client provides a sense of security and prevents
injury. Learning new techniques or discussing triggers is ineffective until the anxiety level
decreases significantly.
5. Which clinical finding is most indicative of Neuroleptic Malignant Syndrome (NMS) in a
patient taking haloperidol?
A. Muscle flaccidity and hypotension
B. Tardive dyskinesia and urinary retention
C. Severe muscle rigidity and hyperpyrexia
D. Excessive salivation and bradycardia
Answer: C
Rationale: NMS is a life-threatening emergency characterized by severe muscle rigidity,
high fever (hyperpyrexia), and autonomic instability. It is a rare but serious reaction to
antipsychotic medications like haloperidol. Prompt recognition and discontinuation of the
drug are critical for survival.
6. A client is diagnosed with Obsessive-Compulsive Disorder (OCD) and spends 2 hours
washing their hands every morning. Initially, what should the nurse do?
A. Lock the bathroom door to prevent the ritual
B. Tell the client they must finish in 10 minutes
C. Confront the client about the irrationality of the behavior
D. Allow enough time for the ritual in the schedule
Answer: D
, Rationale: Initially, the nurse should allow time for the ritual to prevent overwhelming
anxiety that could lead to panic. Over time, the nurse will work with the client to gradually
limit the time spent on the ritual. Abruptly stopping the ritual before the client has
alternative coping mechanisms is counterproductive.
7. A client is being started on Clozapine for treatment-resistant schizophrenia. Which
monitoring requirement is most essential?
A. Weekly white blood cell (WBC) counts
B. Monthly liver function tests
C. Weekly serum potassium levels
D. Daily blood pressure readings
Answer: A
Rationale: Clozapine carries a risk of agranulocytosis, a dangerous drop in white blood
cells that increases infection risk. Strict protocol requires regular WBC and Absolute
Neutrophil Count (ANC) monitoring to continue therapy. This represents an advanced
pharmacological safety application in psychiatric nursing.
8. The nurse identifies that a client is using ‘displacement’ as a defense mechanism when the
client does which of the following?
A. States they don’t have a drinking problem despite being intoxicated
B. Yells at the nurse because their spouse didn’t visit
C. Excellently performs at work to make up for a poor home life
D. Forgets the details of a traumatic car accident
Answer: B
Rationale: Displacement involves transferring emotions from the original source of stress
to a less threatening person or object. In this case, the client is angry at the spouse but
takes it out on the nurse. Understanding defense mechanisms helps nurses interpret client
behavior and manage the therapeutic relationship.
9. A nurse is conducting a suicide risk assessment. Which statement by the client is of the
highest concern?
A. I’ve been feeling really down lately.
B. I wish I could just sleep for a long time.
C. I have a bottle of pills and I’m going to take them tonight.
D. Things would be easier for my family if I wasn’t here.
Answer: C
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client with bipolar disorder is prescribed lithium carbonate. Which laboratory result
should the nurse prioritize for review before administering the next dose?
A. Serum potassium level of 3.8 mEq/L
B. Serum lithium level of 1.8 mEq/L
C. White blood cell count of 8,000/mm3
D. Fast blood glucose of 100 mg/dL
Answer: B
Rationale: A serum lithium level of 1.8 mEq/L indicates toxicity, as the therapeutic range
is generally 0.6 to 1.2 mEq/L. The nurse must hold the dose and notify the provider to
prevent severe complications like seizures or coma. This question tests the nurse’s ability
to prioritize safety based on narrow therapeutic index drug monitoring.
2. A patient in an acute manic phase of bipolar disorder is moving rapidly around the unit,
interrupting others and shouting. Which nursing intervention is most appropriate?
A. Ask the patient to sit in the dayroom and watch a movie
B. Encourage the patient to lead a group exercise session
C. Provide high-calorie finger foods and fluids
D. Place the patient in immediate mechanical restraints
Answer: C
Rationale: Patients in acute mania often cannot sit still long enough to eat a full meal,
leading to nutritional deficits. High-calorie finger foods allow them to eat while moving.
This intervention addresses the physiological integrity of the patient during a period of
hyperactive behavior.
3. A client diagnosed with schizophrenia states, ‘The voices are telling me that the food is
poisoned.’ Which response by the nurse is therapeutic?
A. I don’t hear the voices, but I understand that they are real to you.
B. I don’t hear any voices; you are just having a hallucination.
C. Don’t be silly, the food is fine. I am eating it too.
D. Why do the voices want to poison you?
Answer: A
,Rationale: This response presents reality while validating the client’s feelings without
agreeing with the hallucination. Avoiding ‘why’ questions prevents the client from
becoming defensive or further entrenched in the delusion. This approach builds trust and
maintains a professional therapeutic boundary.
4. A nurse is caring for a client experiencing a panic level of anxiety. Which action should the
nurse take first?
A. Teach the client a new relaxation technique
B. Stay with the client and remain calm
C. Leave the client alone to allow them space to calm down
D. Ask the client to describe what triggered the panic
Answer: B
Rationale: During panic-level anxiety, a person’s safety is the priority because they may
lose touch with reality. Staying with the client provides a sense of security and prevents
injury. Learning new techniques or discussing triggers is ineffective until the anxiety level
decreases significantly.
5. Which clinical finding is most indicative of Neuroleptic Malignant Syndrome (NMS) in a
patient taking haloperidol?
A. Muscle flaccidity and hypotension
B. Tardive dyskinesia and urinary retention
C. Severe muscle rigidity and hyperpyrexia
D. Excessive salivation and bradycardia
Answer: C
Rationale: NMS is a life-threatening emergency characterized by severe muscle rigidity,
high fever (hyperpyrexia), and autonomic instability. It is a rare but serious reaction to
antipsychotic medications like haloperidol. Prompt recognition and discontinuation of the
drug are critical for survival.
6. A client is diagnosed with Obsessive-Compulsive Disorder (OCD) and spends 2 hours
washing their hands every morning. Initially, what should the nurse do?
A. Lock the bathroom door to prevent the ritual
B. Tell the client they must finish in 10 minutes
C. Confront the client about the irrationality of the behavior
D. Allow enough time for the ritual in the schedule
Answer: D
, Rationale: Initially, the nurse should allow time for the ritual to prevent overwhelming
anxiety that could lead to panic. Over time, the nurse will work with the client to gradually
limit the time spent on the ritual. Abruptly stopping the ritual before the client has
alternative coping mechanisms is counterproductive.
7. A client is being started on Clozapine for treatment-resistant schizophrenia. Which
monitoring requirement is most essential?
A. Weekly white blood cell (WBC) counts
B. Monthly liver function tests
C. Weekly serum potassium levels
D. Daily blood pressure readings
Answer: A
Rationale: Clozapine carries a risk of agranulocytosis, a dangerous drop in white blood
cells that increases infection risk. Strict protocol requires regular WBC and Absolute
Neutrophil Count (ANC) monitoring to continue therapy. This represents an advanced
pharmacological safety application in psychiatric nursing.
8. The nurse identifies that a client is using ‘displacement’ as a defense mechanism when the
client does which of the following?
A. States they don’t have a drinking problem despite being intoxicated
B. Yells at the nurse because their spouse didn’t visit
C. Excellently performs at work to make up for a poor home life
D. Forgets the details of a traumatic car accident
Answer: B
Rationale: Displacement involves transferring emotions from the original source of stress
to a less threatening person or object. In this case, the client is angry at the spouse but
takes it out on the nurse. Understanding defense mechanisms helps nurses interpret client
behavior and manage the therapeutic relationship.
9. A nurse is conducting a suicide risk assessment. Which statement by the client is of the
highest concern?
A. I’ve been feeling really down lately.
B. I wish I could just sleep for a long time.
C. I have a bottle of pills and I’m going to take them tonight.
D. Things would be easier for my family if I wasn’t here.
Answer: C
