NUR2459 Final Exam Actual Exam Style
V3 | NUR 2459 Mental and Behavioral
Health Nursing | Rasmussen
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘The voices are telling me to hurt myself.’ Which of the following is the priority nursing
intervention?
A. Ask the client what the voices are saying to them.
B. Provide a quiet, low-stimulation environment.
C. Administer a PRN dose of an antipsychotic medication.
D. Initiate one-on-one constant observation for safety.
Answer: D
Rationale: Safety is the highest priority when a client is experiencing command
hallucinations to harm themselves. Initiating one-on-one observation ensures that the
nurse can intervene immediately if the client attempts to act on the hallucinations. The
nurse must document the client’s behavior and the level of supervision provided according
to facility policy.
,2. A nurse is caring for a client with Bipolar I Disorder who is in an acute manic phase. The
client is moving quickly around the unit, talking loudly, and has not eaten since breakfast.
Which food choice is most appropriate?
A. A chicken salad sandwich
B. A bowl of vegetable soup
C. Spaghetti with meatballs
D. A garden salad with dressing
Answer: A
Rationale: Clients in a manic state often have difficulty sitting down for a complete meal
due to hyperactivity. High-calorie, high-protein finger foods like a sandwich allow the client
to eat while moving around the unit. This intervention helps maintain the client’s
nutritional status and prevents physical exhaustion during the manic episode.
3. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which assessment finding is most concerning to the nurse?
A. The client reports sleeping 12 hours a day.
B. The client expresses feelings of worthlessness and guilt.
C. The client refuses to participate in group therapy sessions.
D. The client suddenly appears happy and energetic after a period of deep depression.
Answer: D
, Rationale: A sudden improvement in mood and energy levels in a severely depressed
client can indicate that the client has made a decision to commit suicide and now feels
relief. The nurse must immediately perform a suicide risk assessment to determine if the
client has a plan or means to end their life. Increased monitoring is necessary during this
high-risk transition period.
4. A nurse is educating a client about a new prescription for Phenelzine, a Monoamine
Oxidase Inhibitor (MAOI). Which food should the nurse instruct the client to avoid?
A. Fresh grilled salmon
B. Cheddar cheese and crackers
C. Mashed potatoes with butter
D. Scrambled eggs with spinach
Answer: B
Rationale: Clients taking MAOIs must avoid foods high in tyramine, such as aged cheeses,
to prevent a hypertensive crisis. Aged cheddar is high in tyramine, whereas fresh foods like
salmon and eggs are generally safe. The nurse should provide a comprehensive list of
restricted foods and beverages to the client.
5. A client is experiencing an acute panic attack. Which of the following actions should the
nurse take first?
A. Teach the client deep breathing techniques.
B. Instruct the client to go to the dayroom and watch TV.
V3 | NUR 2459 Mental and Behavioral
Health Nursing | Rasmussen
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘The voices are telling me to hurt myself.’ Which of the following is the priority nursing
intervention?
A. Ask the client what the voices are saying to them.
B. Provide a quiet, low-stimulation environment.
C. Administer a PRN dose of an antipsychotic medication.
D. Initiate one-on-one constant observation for safety.
Answer: D
Rationale: Safety is the highest priority when a client is experiencing command
hallucinations to harm themselves. Initiating one-on-one observation ensures that the
nurse can intervene immediately if the client attempts to act on the hallucinations. The
nurse must document the client’s behavior and the level of supervision provided according
to facility policy.
,2. A nurse is caring for a client with Bipolar I Disorder who is in an acute manic phase. The
client is moving quickly around the unit, talking loudly, and has not eaten since breakfast.
Which food choice is most appropriate?
A. A chicken salad sandwich
B. A bowl of vegetable soup
C. Spaghetti with meatballs
D. A garden salad with dressing
Answer: A
Rationale: Clients in a manic state often have difficulty sitting down for a complete meal
due to hyperactivity. High-calorie, high-protein finger foods like a sandwich allow the client
to eat while moving around the unit. This intervention helps maintain the client’s
nutritional status and prevents physical exhaustion during the manic episode.
3. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
Which assessment finding is most concerning to the nurse?
A. The client reports sleeping 12 hours a day.
B. The client expresses feelings of worthlessness and guilt.
C. The client refuses to participate in group therapy sessions.
D. The client suddenly appears happy and energetic after a period of deep depression.
Answer: D
, Rationale: A sudden improvement in mood and energy levels in a severely depressed
client can indicate that the client has made a decision to commit suicide and now feels
relief. The nurse must immediately perform a suicide risk assessment to determine if the
client has a plan or means to end their life. Increased monitoring is necessary during this
high-risk transition period.
4. A nurse is educating a client about a new prescription for Phenelzine, a Monoamine
Oxidase Inhibitor (MAOI). Which food should the nurse instruct the client to avoid?
A. Fresh grilled salmon
B. Cheddar cheese and crackers
C. Mashed potatoes with butter
D. Scrambled eggs with spinach
Answer: B
Rationale: Clients taking MAOIs must avoid foods high in tyramine, such as aged cheeses,
to prevent a hypertensive crisis. Aged cheddar is high in tyramine, whereas fresh foods like
salmon and eggs are generally safe. The nurse should provide a comprehensive list of
restricted foods and beverages to the client.
5. A client is experiencing an acute panic attack. Which of the following actions should the
nurse take first?
A. Teach the client deep breathing techniques.
B. Instruct the client to go to the dayroom and watch TV.
