NUR 2459 MENTAL AND BEHAVIORAL
HEALTH NURSING EXAM 2 PRACTICE
QUESTIONS AND ANSWERS
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘The voices are telling me to hurt my roommate.’ Which action by the nurse is the
priority?
A. Ask the client to explain why the voices want the roommate harmed.
B. Place the client in a seclusion room immediately to prevent injury.
C. Notify the roommate and the security team about the potential threat.
D. Initiate one-to-one observation and stay with the client to ensure safety.
Answer: D
Conceptual Explanation: Safety is the priority. Command hallucinations that involve harm
to others require immediate intervention. One-to-one observation ensures the client is
monitored constantly while the nurse assesses further and implements safety protocols.
,2. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result would require the nurse to hold the medication and notify the provider immediately?
A. Serum sodium of 135 mEq/L
B. Platelet count of 150,000/mm³
C. Blood glucose level of 110 mg/dL
D. White blood cell (WBC) count of 2,500/mm³
Answer: D
Conceptual Explanation: Clozapine carries a high risk for agranulocytosis. A WBC count
below 3,000/mm³ or an absolute neutrophil count (ANC) below 1,500/mm³ requires
immediate discontinuation of the drug and medical follow-up.
3. A client with Bipolar I Disorder is in the acute manic phase. Which meal choice is most
appropriate for the nurse to provide?
A. A turkey and cheese wrap with a carton of apple juice
B. Steak and mashed potatoes with a side of corn
C. A bowl of hot vegetable soup and a glass of water
D. Spaghetti with meatballs and a salad
Answer: A
, Conceptual Explanation: Manic clients often have high activity levels and cannot sit long
enough to eat. ‘Finger foods’ that are high in protein and calories allow the client to eat
while moving.
4. A client taking Lithium Carbonate for Bipolar Disorder reports blurred vision, severe
diarrhea, and tremors. The nurse notes the client is confused. What should be the nurse’s
first action?
A. Administer a PRN dose of Lorazepam for the tremors.
B. Encourage the client to drink more fluids to dilute the lithium.
C. Document the findings as common side effects of lithium therapy.
D. Hold the next dose and prepare to obtain a serum lithium level.
Answer: D
Conceptual Explanation: Blurred vision, diarrhea, confusion, and coarse tremors are signs
of moderate to severe lithium toxicity. The nurse must stop the medication and check blood
levels immediately.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which clinical
finding is considered a hallmark sign of this condition?
A. Hyporeflexia and dilated pupils
B. Hypotension and bradycardia
C. Extreme muscle rigidity and high fever
HEALTH NURSING EXAM 2 PRACTICE
QUESTIONS AND ANSWERS
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘The voices are telling me to hurt my roommate.’ Which action by the nurse is the
priority?
A. Ask the client to explain why the voices want the roommate harmed.
B. Place the client in a seclusion room immediately to prevent injury.
C. Notify the roommate and the security team about the potential threat.
D. Initiate one-to-one observation and stay with the client to ensure safety.
Answer: D
Conceptual Explanation: Safety is the priority. Command hallucinations that involve harm
to others require immediate intervention. One-to-one observation ensures the client is
monitored constantly while the nurse assesses further and implements safety protocols.
,2. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result would require the nurse to hold the medication and notify the provider immediately?
A. Serum sodium of 135 mEq/L
B. Platelet count of 150,000/mm³
C. Blood glucose level of 110 mg/dL
D. White blood cell (WBC) count of 2,500/mm³
Answer: D
Conceptual Explanation: Clozapine carries a high risk for agranulocytosis. A WBC count
below 3,000/mm³ or an absolute neutrophil count (ANC) below 1,500/mm³ requires
immediate discontinuation of the drug and medical follow-up.
3. A client with Bipolar I Disorder is in the acute manic phase. Which meal choice is most
appropriate for the nurse to provide?
A. A turkey and cheese wrap with a carton of apple juice
B. Steak and mashed potatoes with a side of corn
C. A bowl of hot vegetable soup and a glass of water
D. Spaghetti with meatballs and a salad
Answer: A
, Conceptual Explanation: Manic clients often have high activity levels and cannot sit long
enough to eat. ‘Finger foods’ that are high in protein and calories allow the client to eat
while moving.
4. A client taking Lithium Carbonate for Bipolar Disorder reports blurred vision, severe
diarrhea, and tremors. The nurse notes the client is confused. What should be the nurse’s
first action?
A. Administer a PRN dose of Lorazepam for the tremors.
B. Encourage the client to drink more fluids to dilute the lithium.
C. Document the findings as common side effects of lithium therapy.
D. Hold the next dose and prepare to obtain a serum lithium level.
Answer: D
Conceptual Explanation: Blurred vision, diarrhea, confusion, and coarse tremors are signs
of moderate to severe lithium toxicity. The nurse must stop the medication and check blood
levels immediately.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which clinical
finding is considered a hallmark sign of this condition?
A. Hyporeflexia and dilated pupils
B. Hypotension and bradycardia
C. Extreme muscle rigidity and high fever
