EXAM
NUR 2459 RASMUSSEN MENTAL HEALTH
EXAM 2 MODULES 1-3 2025-2026
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A person was online continuously for over 24 hours, posting rhymes on official government
web-sites and inviting politicians to join social networks. The person has not slept or eaten for
3 days. What features of mania are evident?
a. Increased muscle tension and anxiety
b. Vegetative signs and poor grooming
c. Poor judgment and hyperactivity
d. Cognitive deficits and paranoia
A+ TEST BANK 1
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EXAM
ANS: C
Hyperactivity (activity without sleep) and poor judgment (posting rhymes on government
web-sites) are characteristic of manic episodes. The distracters do not specifically apply to
mania.
A patient diagnosed with bipolar disorder is dressed in a red leotard and bright scarves. The
patient twirls and shadow boxes. The patient says gaily, "Do you like my scarves? Here; they
are my gift to you." How should the nurse document the patient's mood?
a. Euphoric
b. Irritable
c. Suspicious
d. Confident
ANS: A
The patient has demonstrated clang associations and pleasant, happy behavior. Excessive
happiness indicates euphoria. Irritability, belligerence, excessive happiness, and confidence
are not the best terms for the patient's mood. Suspiciousness is not evident.
A person was directing traffic on a busy street, rapidly shouting, "To work, you jerk, for perks"
and making obscene gestures at cars. The person has not slept or eaten for 3 days. Which as-
sessment findings will have priority concern for this patient's plan of care?
a. Insulting, aggressive behavior
b. Pressured speech and grandiosity
c. Hyperactivity; not eating and sleeping
d. Poor concentration and decision making
ANS: C
Hyperactivity, poor nutrition, hydration, and not sleeping take priority in terms of the needs
listed above because they threaten the physical integrity of the patient. The other behaviors
are less threatening to the patient's life.
A+ TEST BANK 2
, NUR 2459 RASMUSSEN MENTAL HEALTH
EXAM
A patient diagnosed with acute mania has distributed pamphlets about a new business
venture on a street corner for 2 days. Which nursing diagnosis has priority?
a. Risk for injury
b. Ineffective coping
c. Impaired social interaction
d. Ineffective therapeutic regimen manage-ment
ANS: A
Although each of the nursing diagnoses listed is appropriate for a patient having a manic
episode, the priority lies with the patient's physiological safety. Hyperactivity and poor
judgment put the patient at risk for injury.
A patient diagnosed with bipolar disorder becomes hyperactive after discontinuing lithium.
The patient threatens to hit another patient. Which comment by the nurse is appropriate?
a. "Stop that! No one did anything to provoke an attack by you."
b. "If you do that one more time, you will be secluded immediately."
c. "Do not hit anyone. If you are unable to control yourself, we will help you."
d. "You know we will not let you hit anyone. Why do you continue this behavior?"
ANS: C
When the patient is unable to control his or her behavior and violates or threatens to violate
the rights of others, limits must be set in an effort to de-escalate the situation. Limits should
be set in simple, concrete terms. The incorrect responses do not offer appropriate assistance
to the patient, threaten the patient with seclusion as punishment, and ask a rhetorical
question.
This nursing diagnosis applies to a patient with acute mania: Imbalanced nutrition: less than
body requirements related to insufficient caloric intake and hyperactivity as evidenced by 5-
pound weight loss in 4 days. Select an appropriate outcome. The patient will:
a. ask staff for assistance with feeding within 4 days.
A+ TEST BANK 3
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EXAM
b. drink six servings of a high-calorie, high-protein drink each day.
c. consistently sit with others for at least 30 minutes at meal time within 1 week.
d. consistently wear appropriate attire for age and sex within 1 week while on the psy-chiatric
unit.
ANS: B
High-calorie, high-protein food supplements will provide the additional calories needed to
offset the patient's extreme hyperactivity. Sitting with others or asking for assistance does
not mean the patient ate or drank. The other indicator is unrelated to the nursing diagnosis.
7. A patient demonstrating characteristics of acute mania relapsed after discontinuing lithium.
New orders are written to resume lithium twice daily and begin olanzapine (Zyprexa). What is
the rationale for the addition of olanzapine to the medication regimen? It will:
a. minimize the side effects of lithium.
b. bring hyperactivity under rapid control.
c. enhance the antimanic actions of lithium.
d. be used for long-term control of hyperac-tivity.
ANS: B
Manic symptoms are controlled by lithium only after a therapeutic serum level is attained.
Because this takes several days to accomplish, a drug with rapid onset is necessary to reduce
the hyperactiv-ity initially. Antipsychotic drugs neither enhance lithium's antimanic activity nor
minimize the side effects. Lithium will be used for long-term control.
8. A patient diagnosed with bipolar disorder has rapidly changing mood cycles. The health
care provider prescribes an anticonvulsant medication. To prepare teaching materials, which
drug should the nurse anticipate will be prescribed?
a. phenytoin (Dilantin)
b. clonidine (Catapres)
c. risperidone (Risperdal)
d. carbamazepine (Tegretol)
A+ TEST BANK 4