NUR2459/NUR 2459 Exam 2 V2 | Mental
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with obsessive-compulsive disorder (OCD) who spends hours
performing hand-washing rituals. Which nursing intervention is most appropriate initially?
A. Explain to the client that the hands are already clean.
B. Immediately restrict the client’s access to the sink.
C. Administer an antipsychotic medication to stop the behavior.
D. Allow the client enough time to perform the rituals.
Answer: D
Rationale: In the initial phase of treatment for OCD, it is important to allow the client to
perform rituals to avoid escalating their anxiety. Forcing an immediate stop to compulsions
can lead to panic or severe distress. The long-term goal is to gradually limit the time spent
on rituals through cognitive behavioral therapy and medication.
2. Which medication is considered a first-line treatment for generalized anxiety disorder
(GAD)?
A. Haloperidol
B. Sertraline
C. Lithium carbonate
,D. Chlorpromazine
Answer: B
Rationale: Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI) and is considered a
first-line pharmacological treatment for GAD due to its efficacy and safety profile.
Haloperidol and Chlorpromazine are antipsychotics, which are not standard first-line
treatments for primary anxiety disorders. Lithium is primarily used for mood stabilization
in bipolar disorder, not for GAD.
3. A client experiencing a panic attack is hyperventilating and reporting chest pain. What is
the priority nursing action?
A. Stay with the client and offer reassurance of safety.
B. Encourage the client to discuss the source of their stress.
C. Administer an immediate dose of Buspirone.
D. Leave the client alone to allow them space to calm down.
Answer: A
Rationale: During a panic attack, the client’s immediate safety and physical presence of the
nurse are the highest priorities. The nurse should stay with the client, use short and simple
sentences, and provide a calm environment to help de-escalate the situation. Buspirone is
not used for acute panic attacks because it takes several weeks to reach therapeutic
effectiveness.
, 4. A client is diagnosed with Anorexia Nervosa. Which physical finding should the nurse
expect to observe?
A. Tachycardia and hypertension
B. Hyperkalemia and oily skin
C. Excessive perspiration and moist mucous membranes
D. Lanugo and bradycardia
Answer: D
Rationale: Lanugo, which is fine, downy hair, grows on the body as a compensatory
mechanism to provide warmth in clients with extreme weight loss. Bradycardia and
hypotension are also common cardiovascular responses to the body’s starved state. Other
symptoms include cold extremities and amenorrhea in female clients.
5. A client with Bulimia Nervosa is admitted to the unit. Which assessment finding is most
indicative of frequent self-induced vomiting?
A. Thickened hair on the scalp
B. Hyperactive bowel sounds
C. Elevated phosphorus levels
D. Russell’s sign on the knuckles
Answer: D
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with obsessive-compulsive disorder (OCD) who spends hours
performing hand-washing rituals. Which nursing intervention is most appropriate initially?
A. Explain to the client that the hands are already clean.
B. Immediately restrict the client’s access to the sink.
C. Administer an antipsychotic medication to stop the behavior.
D. Allow the client enough time to perform the rituals.
Answer: D
Rationale: In the initial phase of treatment for OCD, it is important to allow the client to
perform rituals to avoid escalating their anxiety. Forcing an immediate stop to compulsions
can lead to panic or severe distress. The long-term goal is to gradually limit the time spent
on rituals through cognitive behavioral therapy and medication.
2. Which medication is considered a first-line treatment for generalized anxiety disorder
(GAD)?
A. Haloperidol
B. Sertraline
C. Lithium carbonate
,D. Chlorpromazine
Answer: B
Rationale: Sertraline is a Selective Serotonin Reuptake Inhibitor (SSRI) and is considered a
first-line pharmacological treatment for GAD due to its efficacy and safety profile.
Haloperidol and Chlorpromazine are antipsychotics, which are not standard first-line
treatments for primary anxiety disorders. Lithium is primarily used for mood stabilization
in bipolar disorder, not for GAD.
3. A client experiencing a panic attack is hyperventilating and reporting chest pain. What is
the priority nursing action?
A. Stay with the client and offer reassurance of safety.
B. Encourage the client to discuss the source of their stress.
C. Administer an immediate dose of Buspirone.
D. Leave the client alone to allow them space to calm down.
Answer: A
Rationale: During a panic attack, the client’s immediate safety and physical presence of the
nurse are the highest priorities. The nurse should stay with the client, use short and simple
sentences, and provide a calm environment to help de-escalate the situation. Buspirone is
not used for acute panic attacks because it takes several weeks to reach therapeutic
effectiveness.
, 4. A client is diagnosed with Anorexia Nervosa. Which physical finding should the nurse
expect to observe?
A. Tachycardia and hypertension
B. Hyperkalemia and oily skin
C. Excessive perspiration and moist mucous membranes
D. Lanugo and bradycardia
Answer: D
Rationale: Lanugo, which is fine, downy hair, grows on the body as a compensatory
mechanism to provide warmth in clients with extreme weight loss. Bradycardia and
hypotension are also common cardiovascular responses to the body’s starved state. Other
symptoms include cold extremities and amenorrhea in female clients.
5. A client with Bulimia Nervosa is admitted to the unit. Which assessment finding is most
indicative of frequent self-induced vomiting?
A. Thickened hair on the scalp
B. Hyperactive bowel sounds
C. Elevated phosphorus levels
D. Russell’s sign on the knuckles
Answer: D
