NUR2459 Final Exam Actual Exam Style
V2 | NUR 2459 Mental and Behavioral
Health Nursing | Rasmussen
1. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following is the priority nursing action?
A. Ask the client directly what the voices are saying.
B. Inform the client that the voices are not real.
C. Increase the dosage of the client’s antipsychotic medication.
D. Place the client in a quiet room with minimal stimulation.
Answer: A
Rationale: The nurse must first assess the content of the hallucinations to determine if
they are command hallucinations that could lead to harm. Safety is the primary concern
when a client is experiencing psychosis. Once the risk is established, further interventions
like medication or environment changes can be considered.
2. A client is prescribed Lithium Carbonate for Bipolar Disorder. Which of the following lab
values should the nurse prioritize?
A. Hemoglobin and Hematocrit
B. Serum Sodium
C. Blood Glucose
,D. Prothrombin Time
Answer: B
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body. If
sodium levels are low, the kidneys retain lithium, potentially leading to toxicity. Monitoring
electrolyte balance is essential for patients on this mood stabilizer.
3. A nurse is assessing a client for potential alcohol withdrawal. Which of the following is an
early sign of withdrawal?
A. Severe hypotension
B. Coarse tremors of the hands
C. Profound bradycardia
D. Hyper-somnolence
Answer: B
Rationale: Early signs of alcohol withdrawal usually appear within 6 to 12 hours after the
last drink and include tremors, anxiety, and tachycardia. Identifying these symptoms early
allows for the administration of benzodiazepines to prevent progression to delirium
tremens. Nurses must use standardized tools like the CIWA scale to monitor these patients.
4. A client with Borderline Personality Disorder is being manipulative and asking for special
privileges. Which nursing intervention is most appropriate?
A. Allow the client to have the privileges once to build rapport.
, B. Discuss the request with the client’s family during visiting hours.
C. Ignore the client’s requests until they stop asking.
D. Explain that the rules apply to everyone and maintain firm boundaries.
Answer: D
Rationale: Consistency and limit-setting are vital for managing clients with personality
disorders who exhibit manipulative behavior. Splitting and boundary-testing are common
traits that require a unified approach from the nursing staff. Maintaining clear expectations
helps provide a structured and safe environment for the client.
5. A client is experiencing a panic attack. Which of the following is the most appropriate
nursing intervention?
A. Leave the client alone to allow them space to calm down.
B. Encourage the client to join a group therapy session immediately.
C. Ask the client to explain the reason for their anxiety.
D. Stay with the client and use short, simple sentences.
Answer: D
Rationale: During a panic attack, the client’s ability to process information is severely
limited due to high levels of anxiety. Staying with the client provides a sense of safety and
reduces the fear of being alone. Simple instructions are necessary because the client cannot
focus on complex tasks or explanations.
V2 | NUR 2459 Mental and Behavioral
Health Nursing | Rasmussen
1. A nurse is caring for a client who has schizophrenia and is experiencing auditory
hallucinations. Which of the following is the priority nursing action?
A. Ask the client directly what the voices are saying.
B. Inform the client that the voices are not real.
C. Increase the dosage of the client’s antipsychotic medication.
D. Place the client in a quiet room with minimal stimulation.
Answer: A
Rationale: The nurse must first assess the content of the hallucinations to determine if
they are command hallucinations that could lead to harm. Safety is the primary concern
when a client is experiencing psychosis. Once the risk is established, further interventions
like medication or environment changes can be considered.
2. A client is prescribed Lithium Carbonate for Bipolar Disorder. Which of the following lab
values should the nurse prioritize?
A. Hemoglobin and Hematocrit
B. Serum Sodium
C. Blood Glucose
,D. Prothrombin Time
Answer: B
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body. If
sodium levels are low, the kidneys retain lithium, potentially leading to toxicity. Monitoring
electrolyte balance is essential for patients on this mood stabilizer.
3. A nurse is assessing a client for potential alcohol withdrawal. Which of the following is an
early sign of withdrawal?
A. Severe hypotension
B. Coarse tremors of the hands
C. Profound bradycardia
D. Hyper-somnolence
Answer: B
Rationale: Early signs of alcohol withdrawal usually appear within 6 to 12 hours after the
last drink and include tremors, anxiety, and tachycardia. Identifying these symptoms early
allows for the administration of benzodiazepines to prevent progression to delirium
tremens. Nurses must use standardized tools like the CIWA scale to monitor these patients.
4. A client with Borderline Personality Disorder is being manipulative and asking for special
privileges. Which nursing intervention is most appropriate?
A. Allow the client to have the privileges once to build rapport.
, B. Discuss the request with the client’s family during visiting hours.
C. Ignore the client’s requests until they stop asking.
D. Explain that the rules apply to everyone and maintain firm boundaries.
Answer: D
Rationale: Consistency and limit-setting are vital for managing clients with personality
disorders who exhibit manipulative behavior. Splitting and boundary-testing are common
traits that require a unified approach from the nursing staff. Maintaining clear expectations
helps provide a structured and safe environment for the client.
5. A client is experiencing a panic attack. Which of the following is the most appropriate
nursing intervention?
A. Leave the client alone to allow them space to calm down.
B. Encourage the client to join a group therapy session immediately.
C. Ask the client to explain the reason for their anxiety.
D. Stay with the client and use short, simple sentences.
Answer: D
Rationale: During a panic attack, the client’s ability to process information is severely
limited due to high levels of anxiety. Staying with the client provides a sense of safety and
reduces the fear of being alone. Simple instructions are necessary because the client cannot
focus on complex tasks or explanations.
