NUR2459/NUR 2459 Exam 2 V3 | Mental
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Bipolar Disorder who is experiencing a manic episode. The
client is moving rapidly and using pressured speech. Which of the following nursing
interventions is the priority?
A. Provide the client with a detailed schedule of group activities.
B. Encourage the client to join a competitive basketball game.
C. Offer high-calorie finger foods and fluids.
D. Ask the client to explain the meaning of their rapid speech.
Answer: C
Rationale: During a manic episode, clients often cannot sit still long enough to eat a full
meal. Providing high-calorie finger foods allows them to maintain nutrition while on the
move. This prevents exhaustion and physical depletion during the high-energy phase of
mania.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Potassium level
B. Blood Glucose level
,C. Serum Sodium level
D. White Blood Cell count
Answer: C
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body. If
sodium levels drop, the kidneys will retain lithium, leading to toxicity. The nurse must
educate the client to maintain a consistent intake of salt and fluids.
3. A client with Schizophrenia is experiencing auditory hallucinations, stating, ‘The voices are
telling me to hurt myself.’ Which is the best initial response by the nurse?
A. ‘I believe you, but I do not hear the voices myself.’
B. ‘Don’t worry, the voices are not real.’
C. ‘Why do you think the voices are saying that?’
D. ‘Let’s go to the dayroom and watch television.’
Answer: A
Rationale: Acknowledging the client’s experience while presenting reality is a therapeutic
communication technique. By stating ‘I do not hear the voices,’ the nurse validates the
client’s feelings without reinforcing the hallucination. This helps build trust while
maintaining a focus on the real environment.
, 4. A nurse is monitoring a client taking Clozapine. Which of the following findings should be
reported to the provider immediately?
A. A sore throat and fever
B. Dry mouth and constipation
C. Weight gain of 2 pounds in a week
D. Drowsiness in the afternoon
Answer: A
Rationale: Clozapine carries a high risk of agranulocytosis, which is a dangerous drop in
white blood cell count. A sore throat and fever are early signs of infection that may indicate
this condition. Immediate medical intervention and blood work are necessary to ensure the
client’s safety.
5. A client is admitted after a suicide attempt. Which of the following actions should the
nurse prioritize to ensure the client’s safety?
A. Allow the client to keep their personal shaver for grooming.
B. Place the client in a room at the end of the hall for privacy.
C. Search the client’s belongings for potentially harmful items.
D. Wait for the client to bring up their feelings about the attempt.
Answer: C
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Bipolar Disorder who is experiencing a manic episode. The
client is moving rapidly and using pressured speech. Which of the following nursing
interventions is the priority?
A. Provide the client with a detailed schedule of group activities.
B. Encourage the client to join a competitive basketball game.
C. Offer high-calorie finger foods and fluids.
D. Ask the client to explain the meaning of their rapid speech.
Answer: C
Rationale: During a manic episode, clients often cannot sit still long enough to eat a full
meal. Providing high-calorie finger foods allows them to maintain nutrition while on the
move. This prevents exhaustion and physical depletion during the high-energy phase of
mania.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value should the nurse monitor most closely to prevent toxicity?
A. Serum Potassium level
B. Blood Glucose level
,C. Serum Sodium level
D. White Blood Cell count
Answer: C
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels in the body. If
sodium levels drop, the kidneys will retain lithium, leading to toxicity. The nurse must
educate the client to maintain a consistent intake of salt and fluids.
3. A client with Schizophrenia is experiencing auditory hallucinations, stating, ‘The voices are
telling me to hurt myself.’ Which is the best initial response by the nurse?
A. ‘I believe you, but I do not hear the voices myself.’
B. ‘Don’t worry, the voices are not real.’
C. ‘Why do you think the voices are saying that?’
D. ‘Let’s go to the dayroom and watch television.’
Answer: A
Rationale: Acknowledging the client’s experience while presenting reality is a therapeutic
communication technique. By stating ‘I do not hear the voices,’ the nurse validates the
client’s feelings without reinforcing the hallucination. This helps build trust while
maintaining a focus on the real environment.
, 4. A nurse is monitoring a client taking Clozapine. Which of the following findings should be
reported to the provider immediately?
A. A sore throat and fever
B. Dry mouth and constipation
C. Weight gain of 2 pounds in a week
D. Drowsiness in the afternoon
Answer: A
Rationale: Clozapine carries a high risk of agranulocytosis, which is a dangerous drop in
white blood cell count. A sore throat and fever are early signs of infection that may indicate
this condition. Immediate medical intervention and blood work are necessary to ensure the
client’s safety.
5. A client is admitted after a suicide attempt. Which of the following actions should the
nurse prioritize to ensure the client’s safety?
A. Allow the client to keep their personal shaver for grooming.
B. Place the client in a room at the end of the hall for privacy.
C. Search the client’s belongings for potentially harmful items.
D. Wait for the client to bring up their feelings about the attempt.
Answer: C
