NUR2459 Final Exam Actual Exam Style
V1 | NUR 2459 Mental and Behavioral
Health Nursing | Rasmussen
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
nursing interventions is the priority?
A. Encourage the client to join a group therapy session.
B. Provide high-calorie finger foods for the client.
C. Set strict limits on the client’s behavior in the common room.
D. Administer a sedative to ensure the client sleeps for 8 hours.
Answer: B
Rationale: During a manic episode, clients are often too active to sit down for full meals,
making nutrition a significant concern. Providing high-calorie finger foods allows the client
to maintain adequate nutritional intake while remaining mobile. This intervention
addresses the physiological need for energy and prevents exhaustion or weight loss.
2. A client is prescribed Lithium Carbonate for bipolar disorder. Which laboratory value
should the nurse monitor closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
C. Serum Calcium
,D. Serum Magnesium
Answer: A
Rationale: Lithium is a salt, and its excretion by the kidneys is closely tied to sodium levels
in the body. If sodium levels are low, the kidneys will retain lithium, leading to toxic levels
in the blood. The nurse must educate the client on maintaining a consistent intake of salt
and water to avoid complications.
3. Which therapeutic communication technique is being used when the nurse says, ‘You say
you’re feeling angry, but you’re smiling’?
A. Reflecting
B. Restating
C. Confrontation
D. Clarification
Answer: C
Rationale: Confrontation is used to point out inconsistencies between a client’s verbal and
non-verbal behaviors. This technique helps the client recognize their own defense
mechanisms or conflicting feelings. It should be used only after a therapeutic relationship
has been established to avoid making the client feel attacked.
4. A nurse is assessing a client for potential suicide risk. Which of the following statements by
the client is the most significant indicator of immediate danger?
A. I have a plan and a gun at home to end it all tonight.
, B. I don’t think my family would miss me if I were gone.
C. I have been feeling really down for a few weeks.
D. I wish I could just sleep and never wake up again.
Answer: A
Rationale: The presence of a specific, lethal plan and access to the means (a gun) indicates
a high and immediate risk for suicide. Nurses must prioritize safety by assessing the
lethality and availability of the client’s methods. This statement requires immediate
intervention, such as constant observation and environmental safety checks.
5. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse’s best
initial response?
A. Ask the client, ‘What are the voices telling you to do?’
B. Tell the client that there are no voices and they are imagining it.
C. Ignore the client’s comment to avoid reinforcing the hallucination.
D. Agree with the client that the voices are scary to build rapport.
Answer: A
Rationale: Safety is the priority when a client is hallucinating, especially to determine if the
voices are ‘commanding’ the client to hurt themselves or others. Asking what the voices are
saying helps the nurse assess for danger. The nurse should acknowledge that the client is
hearing something while also stating that they do not hear the voices themselves.
V1 | NUR 2459 Mental and Behavioral
Health Nursing | Rasmussen
1. A nurse is caring for a client who is experiencing a manic episode. Which of the following
nursing interventions is the priority?
A. Encourage the client to join a group therapy session.
B. Provide high-calorie finger foods for the client.
C. Set strict limits on the client’s behavior in the common room.
D. Administer a sedative to ensure the client sleeps for 8 hours.
Answer: B
Rationale: During a manic episode, clients are often too active to sit down for full meals,
making nutrition a significant concern. Providing high-calorie finger foods allows the client
to maintain adequate nutritional intake while remaining mobile. This intervention
addresses the physiological need for energy and prevents exhaustion or weight loss.
2. A client is prescribed Lithium Carbonate for bipolar disorder. Which laboratory value
should the nurse monitor closely to prevent toxicity?
A. Serum Sodium
B. Serum Potassium
C. Serum Calcium
,D. Serum Magnesium
Answer: A
Rationale: Lithium is a salt, and its excretion by the kidneys is closely tied to sodium levels
in the body. If sodium levels are low, the kidneys will retain lithium, leading to toxic levels
in the blood. The nurse must educate the client on maintaining a consistent intake of salt
and water to avoid complications.
3. Which therapeutic communication technique is being used when the nurse says, ‘You say
you’re feeling angry, but you’re smiling’?
A. Reflecting
B. Restating
C. Confrontation
D. Clarification
Answer: C
Rationale: Confrontation is used to point out inconsistencies between a client’s verbal and
non-verbal behaviors. This technique helps the client recognize their own defense
mechanisms or conflicting feelings. It should be used only after a therapeutic relationship
has been established to avoid making the client feel attacked.
4. A nurse is assessing a client for potential suicide risk. Which of the following statements by
the client is the most significant indicator of immediate danger?
A. I have a plan and a gun at home to end it all tonight.
, B. I don’t think my family would miss me if I were gone.
C. I have been feeling really down for a few weeks.
D. I wish I could just sleep and never wake up again.
Answer: A
Rationale: The presence of a specific, lethal plan and access to the means (a gun) indicates
a high and immediate risk for suicide. Nurses must prioritize safety by assessing the
lethality and availability of the client’s methods. This statement requires immediate
intervention, such as constant observation and environmental safety checks.
5. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse’s best
initial response?
A. Ask the client, ‘What are the voices telling you to do?’
B. Tell the client that there are no voices and they are imagining it.
C. Ignore the client’s comment to avoid reinforcing the hallucination.
D. Agree with the client that the voices are scary to build rapport.
Answer: A
Rationale: Safety is the priority when a client is hallucinating, especially to determine if the
voices are ‘commanding’ the client to hurt themselves or others. Asking what the voices are
saying helps the nurse assess for danger. The nurse should acknowledge that the client is
hearing something while also stating that they do not hear the voices themselves.
