NUR2459 Final Exam Actual Exam Style V2
| NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Stay with the client and remain calm.
B. Teach the client relaxation techniques for future use.
C. Ask the client to describe what triggered the attack.
D. Administer an oral benzodiazepine immediately.
Correct Answer: A
Expert Explanation: The nurse’s first priority during a panic attack is to ensure the client’s
safety and reduce anxiety by staying with them. Remaining calm and using short, simple
sentences helps the client feel supported and less overwhelmed. Other interventions, like
teaching or exploration, should only occur after the acute crisis has passed.
2. A client is admitted with a diagnosis of Schizophrenia and is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. Why do you think the voices are talking to you right now?
B. I do not hear the voices, but I understand that they are real to you.
C. There are no voices; you are just imagining things because of your illness.
,D. What are the voices telling you to do exactly?
Correct Answer: B
Expert Explanation: Acknowledging the client’s experience without agreeing with the
hallucination is a key therapeutic communication technique. This approach provides reality
testing while validating the client’s feelings of distress. Asking ‘why’ or being dismissive can
increase the client’s defensive behavior or paranoia.
3. A nurse is monitoring a client taking Lithium Carbonate for Bipolar Disorder. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Coarse hand tremors and confusion.
B. Fine hand tremors and nausea.
C. Mild thirst and polyuria.
D. Weight gain of five pounds in a month.
Correct Answer: A
Expert Explanation: Coarse hand tremors, confusion, and ataxia are significant indicators
of lithium toxicity that require immediate medical attention. Mild thirst and fine tremors
are common expected side effects during the initiation of therapy but do not necessarily
indicate toxicity. The nurse must monitor serum levels closely to ensure they stay within
the narrow therapeutic range of 0.6 to 1.2 mEq/L.
,4. A client with Depression is prescribed Phenelzine, an MAOI. Which food item should the
nurse instruct the client to avoid?
A. Fresh green leafy vegetables.
B. Whole grain bread and oranges.
C. Broiled chicken breast and white rice.
D. Aged cheddar cheese and pepperoni.
Correct Answer: D
Expert Explanation: Phenelzine and other MAOIs interact with tyramine-rich foods, which
can lead to a hypertensive crisis. Foods like aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided. The nurse should educate the
client on identifying these foods to prevent potentially fatal cardiovascular complications.
5. A nurse is evaluating a client for Extrapyramidal Symptoms (EPS) while taking Haloperidol.
Which finding is characteristic of Akathisia?
A. Involuntary upward deviation of the eyes.
B. Sense of inner restlessness and inability to sit still.
C. Muscle contractions of the neck and face.
D. Mask-like facial expression and shuffling gait.
Correct Answer: B
, Expert Explanation: Akathisia is characterized by a subjective feeling of motor
restlessness and an urgent need to move. Clients often pace the floor or shift their weight
back and forth constantly. Differentiating this from worsening agitation is crucial for
adjusting the antipsychotic dosage correctly.
6. A client is being treated for Borderline Personality Disorder. Which of the following
behaviors is most characteristic of this diagnosis?
A. Extreme shyness and avoidance of social situations.
B. Grandiosity and a lack of empathy for others.
C. Preoccupation with orderliness, perfectionism, and control.
D. Splitting, where staff members are seen as either all good or all bad.
Correct Answer: D
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where the individual cannot integrate positive and negative qualities of others.
This leads to unstable relationships and frequent conflicts within the healthcare team. The
nurse should maintain consistent boundaries and use a team-based approach to minimize
the effects of splitting.
7. A nurse is caring for a client with Anorexia Nervosa who is starting a refeeding program.
Which laboratory value is the priority to monitor?
A. Hemoglobin level
B. Serum Creatinine
| NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client who is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Stay with the client and remain calm.
B. Teach the client relaxation techniques for future use.
C. Ask the client to describe what triggered the attack.
D. Administer an oral benzodiazepine immediately.
Correct Answer: A
Expert Explanation: The nurse’s first priority during a panic attack is to ensure the client’s
safety and reduce anxiety by staying with them. Remaining calm and using short, simple
sentences helps the client feel supported and less overwhelmed. Other interventions, like
teaching or exploration, should only occur after the acute crisis has passed.
2. A client is admitted with a diagnosis of Schizophrenia and is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. Why do you think the voices are talking to you right now?
B. I do not hear the voices, but I understand that they are real to you.
C. There are no voices; you are just imagining things because of your illness.
,D. What are the voices telling you to do exactly?
Correct Answer: B
Expert Explanation: Acknowledging the client’s experience without agreeing with the
hallucination is a key therapeutic communication technique. This approach provides reality
testing while validating the client’s feelings of distress. Asking ‘why’ or being dismissive can
increase the client’s defensive behavior or paranoia.
3. A nurse is monitoring a client taking Lithium Carbonate for Bipolar Disorder. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Coarse hand tremors and confusion.
B. Fine hand tremors and nausea.
C. Mild thirst and polyuria.
D. Weight gain of five pounds in a month.
Correct Answer: A
Expert Explanation: Coarse hand tremors, confusion, and ataxia are significant indicators
of lithium toxicity that require immediate medical attention. Mild thirst and fine tremors
are common expected side effects during the initiation of therapy but do not necessarily
indicate toxicity. The nurse must monitor serum levels closely to ensure they stay within
the narrow therapeutic range of 0.6 to 1.2 mEq/L.
,4. A client with Depression is prescribed Phenelzine, an MAOI. Which food item should the
nurse instruct the client to avoid?
A. Fresh green leafy vegetables.
B. Whole grain bread and oranges.
C. Broiled chicken breast and white rice.
D. Aged cheddar cheese and pepperoni.
Correct Answer: D
Expert Explanation: Phenelzine and other MAOIs interact with tyramine-rich foods, which
can lead to a hypertensive crisis. Foods like aged cheeses, cured meats, and fermented
products are high in tyramine and must be strictly avoided. The nurse should educate the
client on identifying these foods to prevent potentially fatal cardiovascular complications.
5. A nurse is evaluating a client for Extrapyramidal Symptoms (EPS) while taking Haloperidol.
Which finding is characteristic of Akathisia?
A. Involuntary upward deviation of the eyes.
B. Sense of inner restlessness and inability to sit still.
C. Muscle contractions of the neck and face.
D. Mask-like facial expression and shuffling gait.
Correct Answer: B
, Expert Explanation: Akathisia is characterized by a subjective feeling of motor
restlessness and an urgent need to move. Clients often pace the floor or shift their weight
back and forth constantly. Differentiating this from worsening agitation is crucial for
adjusting the antipsychotic dosage correctly.
6. A client is being treated for Borderline Personality Disorder. Which of the following
behaviors is most characteristic of this diagnosis?
A. Extreme shyness and avoidance of social situations.
B. Grandiosity and a lack of empathy for others.
C. Preoccupation with orderliness, perfectionism, and control.
D. Splitting, where staff members are seen as either all good or all bad.
Correct Answer: D
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where the individual cannot integrate positive and negative qualities of others.
This leads to unstable relationships and frequent conflicts within the healthcare team. The
nurse should maintain consistent boundaries and use a team-based approach to minimize
the effects of splitting.
7. A nurse is caring for a client with Anorexia Nervosa who is starting a refeeding program.
Which laboratory value is the priority to monitor?
A. Hemoglobin level
B. Serum Creatinine
