NUR2459 Exam 2 Actual Exam Style V1 |
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A patient experiencing a panic attack is hyperventilating. Which nursing intervention is the
priority?
A. Stay with the patient and provide a calm, quiet environment.
B. Ask the patient to describe the triggers of their anxiety.
C. Teach the patient deep breathing exercises for future use.
D. Administer a scheduled dose of an SSRI medication.
Answer: A
Rationale: The nurse’s priority during a panic attack is to ensure the patient’s safety and
provide a sense of security. Staying with the patient helps reduce the feeling of
abandonment and escalating terror. A calm environment helps decrease external stimuli
that could worsen the patient’s physiological state.
2. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily washing their
hands. What is the most appropriate initial nursing action?
A. Allow the client time for the ritual but set limits on the duration.
B. Tell the client that their hands are clean enough.
C. Lock the bathroom door to prevent the client from washing.
,D. Force the client to stop the ritual immediately to reduce anxiety.
Answer: A
Rationale: Initial treatment for OCD involves allowing the ritualistic behavior to prevent
an overwhelming spike in anxiety. Abruptly stopping the ritual can lead to panic and loss of
control for the client. The nurse should gradually work with the client to set time limits and
replace the behavior with healthier coping mechanisms.
3. A nurse is educating a client starting Lithium for Bipolar Disorder. Which statement by the
client indicates an understanding of the teaching?
A. I will limit my fluid intake to 1 liter per day.
B. I will call my doctor if I experience tremors or blurred vision.
C. I need to stop eating salt entirely to prevent toxicity.
D. I can stop taking the medication once my mood is stable.
Answer: B
Rationale: Tremors and blurred vision are early signs of lithium toxicity that require
immediate medical attention. Clients on Lithium must maintain a consistent intake of
sodium and fluids to avoid toxicity. Stopping the medication abruptly can cause a relapse of
manic symptoms.
4. Which assessment finding is a hallmark symptom of Generalized Anxiety Disorder (GAD)?
A. Checking the stove multiple times before leaving the house.
, B. Sudden episodes of intense fear without a clear cause.
C. Flashbacks related to a previous traumatic event.
D. Excessive worry about multiple events for at least six months.
Answer: D
Rationale: GAD is characterized by persistent and excessive worry about various things
that lasts for 6 months or longer. Clients often find it difficult to control the worry, which
interferes with daily functioning. Unlike panic disorder, GAD is a chronic, low-level state of
anxiety rather than acute attacks.
5. A client is prescribed Phenelzine (an MAOI). The nurse should instruct the client to avoid
which of the following foods?
A. Fresh green leafy vegetables.
B. Skim milk and cottage cheese.
C. Whole grain breads and cereals.
D. Aged cheeses and fermented meats.
Answer: D
Rationale: Foods high in tyramine, such as aged cheeses and fermented meats, can trigger
a hypertensive crisis in clients taking MAOIs. This occurs because the medication inhibits
the breakdown of tyramine in the body. The nurse must provide a comprehensive list of
restricted foods to ensure patient safety.
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A patient experiencing a panic attack is hyperventilating. Which nursing intervention is the
priority?
A. Stay with the patient and provide a calm, quiet environment.
B. Ask the patient to describe the triggers of their anxiety.
C. Teach the patient deep breathing exercises for future use.
D. Administer a scheduled dose of an SSRI medication.
Answer: A
Rationale: The nurse’s priority during a panic attack is to ensure the patient’s safety and
provide a sense of security. Staying with the patient helps reduce the feeling of
abandonment and escalating terror. A calm environment helps decrease external stimuli
that could worsen the patient’s physiological state.
2. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily washing their
hands. What is the most appropriate initial nursing action?
A. Allow the client time for the ritual but set limits on the duration.
B. Tell the client that their hands are clean enough.
C. Lock the bathroom door to prevent the client from washing.
,D. Force the client to stop the ritual immediately to reduce anxiety.
Answer: A
Rationale: Initial treatment for OCD involves allowing the ritualistic behavior to prevent
an overwhelming spike in anxiety. Abruptly stopping the ritual can lead to panic and loss of
control for the client. The nurse should gradually work with the client to set time limits and
replace the behavior with healthier coping mechanisms.
3. A nurse is educating a client starting Lithium for Bipolar Disorder. Which statement by the
client indicates an understanding of the teaching?
A. I will limit my fluid intake to 1 liter per day.
B. I will call my doctor if I experience tremors or blurred vision.
C. I need to stop eating salt entirely to prevent toxicity.
D. I can stop taking the medication once my mood is stable.
Answer: B
Rationale: Tremors and blurred vision are early signs of lithium toxicity that require
immediate medical attention. Clients on Lithium must maintain a consistent intake of
sodium and fluids to avoid toxicity. Stopping the medication abruptly can cause a relapse of
manic symptoms.
4. Which assessment finding is a hallmark symptom of Generalized Anxiety Disorder (GAD)?
A. Checking the stove multiple times before leaving the house.
, B. Sudden episodes of intense fear without a clear cause.
C. Flashbacks related to a previous traumatic event.
D. Excessive worry about multiple events for at least six months.
Answer: D
Rationale: GAD is characterized by persistent and excessive worry about various things
that lasts for 6 months or longer. Clients often find it difficult to control the worry, which
interferes with daily functioning. Unlike panic disorder, GAD is a chronic, low-level state of
anxiety rather than acute attacks.
5. A client is prescribed Phenelzine (an MAOI). The nurse should instruct the client to avoid
which of the following foods?
A. Fresh green leafy vegetables.
B. Skim milk and cottage cheese.
C. Whole grain breads and cereals.
D. Aged cheeses and fermented meats.
Answer: D
Rationale: Foods high in tyramine, such as aged cheeses and fermented meats, can trigger
a hypertensive crisis in clients taking MAOIs. This occurs because the medication inhibits
the breakdown of tyramine in the body. The nurse must provide a comprehensive list of
restricted foods to ensure patient safety.
