NUR2459/NUR 2459 Exam 2 V1 | Mental
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
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. Administer a PRN dose of lorazepam
C. Ask the client to describe their feelings in detail
D. Teach the client relaxation techniques
Answer: A
Rationale: The nurse’s first priority during a panic attack is to ensure the client’s safety
and provide a sense of security. Staying with the client conveys support and helps reduce
the feeling of impending doom. Once the acute anxiety has lessened, other interventions
like teaching or medication can be considered.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following instructions should the nurse include in the teaching?
A. Limit sodium intake to 1 gram per day
B. Maintain a consistent fluid intake of 2 to 3 liters per day
C. Take the medication on an empty stomach
,D. Expect a weight loss of 5 to 10 pounds initially
Answer: B
Rationale: Lithium is a salt and is excreted by the kidneys, so maintaining fluid and
electrolyte balance is crucial to prevent toxicity. Clients should maintain consistent sodium
intake rather than restricting it because low sodium levels can lead to lithium retention.
Drinking 2 to 3 liters of water daily helps maintain renal function and stable lithium levels.
3. A nurse is assessing a client with schizophrenia who reports hearing voices telling them
that the food is poisoned. How should the nurse respond?
A. ‘I don’t hear the voices, but I can see that you are frightened.’
B. ‘The food is not poisoned, and the voices are not real.’
C. ‘Why do you think the voices are saying the food is poisoned?’
D. ‘I will taste the food for you to prove it is safe.’
Answer: A
Rationale: The nurse should acknowledge the client’s feelings without validating the
hallucination itself. By stating that they do not hear the voices, the nurse provides a reality
check while still being empathetic to the client’s distress. Arguing with the client or asking
‘why’ can increase defensiveness and anxiety.
4. A client diagnosed with borderline personality disorder is being manipulative and trying to
pit staff members against each other. This behavior is known as:
A. Projection
, B. Splitting
C. Dissociation
D. Rationalization
Answer: B
Rationale: Splitting is a common defense mechanism in borderline personality disorder
where the individual views people or situations as either all good or all bad. This behavior
often creates conflict among the treatment team as the client praises some staff while
devaluing others. Consistent communication among the staff is essential to manage this
behavior effectively.
5. Which of the following findings is a priority to report to the provider for a client taking
clozapine?
A. WBC count of 2,500/mm3
B. Drowsiness and sedation
C. Weight gain of 2 lbs in a week
D. Increased salivation
Answer: A
Rationale: Clozapine carries a high risk for agranulocytosis, which is a severe and
dangerous reduction in white blood cell count. A WBC count of 2,500/mm3 is below the
normal range and puts the client at high risk for infection. The nurse must monitor
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
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. Administer a PRN dose of lorazepam
C. Ask the client to describe their feelings in detail
D. Teach the client relaxation techniques
Answer: A
Rationale: The nurse’s first priority during a panic attack is to ensure the client’s safety
and provide a sense of security. Staying with the client conveys support and helps reduce
the feeling of impending doom. Once the acute anxiety has lessened, other interventions
like teaching or medication can be considered.
2. A client is prescribed lithium carbonate for the treatment of bipolar disorder. Which of the
following instructions should the nurse include in the teaching?
A. Limit sodium intake to 1 gram per day
B. Maintain a consistent fluid intake of 2 to 3 liters per day
C. Take the medication on an empty stomach
,D. Expect a weight loss of 5 to 10 pounds initially
Answer: B
Rationale: Lithium is a salt and is excreted by the kidneys, so maintaining fluid and
electrolyte balance is crucial to prevent toxicity. Clients should maintain consistent sodium
intake rather than restricting it because low sodium levels can lead to lithium retention.
Drinking 2 to 3 liters of water daily helps maintain renal function and stable lithium levels.
3. A nurse is assessing a client with schizophrenia who reports hearing voices telling them
that the food is poisoned. How should the nurse respond?
A. ‘I don’t hear the voices, but I can see that you are frightened.’
B. ‘The food is not poisoned, and the voices are not real.’
C. ‘Why do you think the voices are saying the food is poisoned?’
D. ‘I will taste the food for you to prove it is safe.’
Answer: A
Rationale: The nurse should acknowledge the client’s feelings without validating the
hallucination itself. By stating that they do not hear the voices, the nurse provides a reality
check while still being empathetic to the client’s distress. Arguing with the client or asking
‘why’ can increase defensiveness and anxiety.
4. A client diagnosed with borderline personality disorder is being manipulative and trying to
pit staff members against each other. This behavior is known as:
A. Projection
, B. Splitting
C. Dissociation
D. Rationalization
Answer: B
Rationale: Splitting is a common defense mechanism in borderline personality disorder
where the individual views people or situations as either all good or all bad. This behavior
often creates conflict among the treatment team as the client praises some staff while
devaluing others. Consistent communication among the staff is essential to manage this
behavior effectively.
5. Which of the following findings is a priority to report to the provider for a client taking
clozapine?
A. WBC count of 2,500/mm3
B. Drowsiness and sedation
C. Weight gain of 2 lbs in a week
D. Increased salivation
Answer: A
Rationale: Clozapine carries a high risk for agranulocytosis, which is a severe and
dangerous reduction in white blood cell count. A WBC count of 2,500/mm3 is below the
normal range and puts the client at high risk for infection. The nurse must monitor
