NUR 2459 Exam 4 Actual Exam V3 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A client diagnosed with schizophrenia is prescribed Clozapine. Which laboratory result
must the nurse review before administering the next dose?
A. Platelet count
B. Blood urea nitrogen (BUN)
C. Serum potassium level
D. White blood cell (WBC) count
Answer: D
Rationale: Clozapine is associated with a significant risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. The nurse must ensure the absolute neutrophil
count and WBC are within safe limits before every administration. Monitoring these levels
is a mandatory safety protocol to prevent severe infection or sepsis.
2. A nurse is caring for a client in the manic phase of bipolar disorder. Which nursing
intervention is the priority for this client?
A. Encouraging the client to join a group therapy session
B. Providing a high-calorie finger food diet
C. Teaching the client about medication side effects
D. Allowing the client to lead a ward meeting
Answer: B
Rationale: Clients in a manic state often experience excessive physical activity and are
unable to sit still long enough to eat. High-calorie finger foods allow the client to consume
necessary nutrients while on the move, preventing physical exhaustion and weight loss.
Safety and physiological stability are the primary concerns during an acute manic episode.
3. Which clinical finding is most indicative of Lithium toxicity in a client with bipolar disorder?
A. Mild thirst
B. Coarse tremors and blurred vision
C. Fine hand tremors
D. Occasional nausea
Answer: B
,Rationale: While fine tremors are a common side effect of Lithium, coarse tremors, ataxia,
and blurred vision indicate advanced toxicity. The nurse must recognize these signs as a
medical emergency requiring immediate serum level testing. Failure to identify these
symptoms could lead to seizures, coma, or permanent neurological damage.
4. A client is admitted for Alcohol Withdrawal Syndrome. Which assessment finding indicates
a need for immediate intervention with IV benzodiazepines?
A. Diaphoresis and anxiety
B. Mild hand tremors
C. Tachycardia and visual hallucinations
D. Report of a headache
Answer: C
Rationale: Tachycardia combined with hallucinations suggests the progression into
Delirium Tremens, a life-threatening stage of withdrawal. Immediate pharmacological
intervention is necessary to prevent seizures and cardiovascular collapse. Monitoring vital
signs and mental status is critical during the first 48 to 72 hours of cessation.
5. An adolescent client is hospitalized with Anorexia Nervosa. Which vital sign change most
likely indicates a need for hospitalization?
A. Respiratory rate of 16 breaths per minute
B. Blood pressure of 110/70 mmHg
C. Body temperature of 98.2°F
D. Heart rate of 38 beats per minute
Answer: D
Rationale: Severe bradycardia, such as a heart rate below 40 bpm, indicates significant
cardiovascular compromise in clients with anorexia. This physiological instability requires
inpatient medical stabilization to prevent sudden cardiac arrest. Other stable vital signs do
not negate the emergency status of the heart rate.
6. A nurse is teaching a client about a newly prescribed Monoamine Oxidase Inhibitor
(MAOI). Which food choice should the nurse instruct the client to avoid?
A. Fresh chicken and rice
B. Steamed broccoli and carrots
C. Aged cheddar cheese and salami
D. Whole grain bread and butter
Answer: C
, Rationale: MAOIs interact with tyramine-rich foods like aged cheese and cured meats to
cause a hypertensive crisis. This interaction results in massive norepinephrine release,
potentially causing stroke or organ damage. Education must emphasize strict dietary
adherence to prevent this life-threatening complication.
7. A client with Borderline Personality Disorder uses ‘splitting’ when interacting with staff.
How should the nurse respond?
A. Agree with the client that certain staff members are better than others
B. Maintain open communication with the treatment team to ensure consistent limits
C. Encourage the client to discuss feelings with the staff member they dislike
D. Offer the client extra privileges to build rapport
Answer: B
Rationale: Splitting is a defense mechanism where the client perceives others as all good
or all bad. This behavior often leads to staff conflict and manipulation within the milieu.
Consistent limit-setting and team communication are essential to provide a stable
therapeutic environment.
8. The nurse is evaluating a client for Serotonin Syndrome. Which symptoms should the nurse
expect to find?
A. Hypotension, bradycardia, and lethargy
B. Increased appetite, weight gain, and somnolence
C. Constipation, urinary retention, and dry mouth
D. Muscle rigidity, fever, and tachycardia
Answer: D
Rationale: Serotonin syndrome is an over-activation of serotonin receptors characterized
by autonomic instability and neuromuscular hyperactivity. Clinical manifestations include
high fever, tachycardia, and hyperreflexia or rigidity. This condition is often precipitated by
the combination of multiple serotonergic agents.
9. A client has been prescribed Haloperidol. The nurse observes the client has a high fever,
muscle stiffness, and unstable blood pressure. Which complication does the nurse suspect?
A. Tardive Dyskinesia
B. Acute Dystonia
C. Pseudoparkinsonism
D. Neuroleptic Malignant Syndrome (NMS)
Answer: D
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A client diagnosed with schizophrenia is prescribed Clozapine. Which laboratory result
must the nurse review before administering the next dose?
A. Platelet count
B. Blood urea nitrogen (BUN)
C. Serum potassium level
D. White blood cell (WBC) count
Answer: D
Rationale: Clozapine is associated with a significant risk of agranulocytosis, which is a life-
threatening decrease in white blood cells. The nurse must ensure the absolute neutrophil
count and WBC are within safe limits before every administration. Monitoring these levels
is a mandatory safety protocol to prevent severe infection or sepsis.
2. A nurse is caring for a client in the manic phase of bipolar disorder. Which nursing
intervention is the priority for this client?
A. Encouraging the client to join a group therapy session
B. Providing a high-calorie finger food diet
C. Teaching the client about medication side effects
D. Allowing the client to lead a ward meeting
Answer: B
Rationale: Clients in a manic state often experience excessive physical activity and are
unable to sit still long enough to eat. High-calorie finger foods allow the client to consume
necessary nutrients while on the move, preventing physical exhaustion and weight loss.
Safety and physiological stability are the primary concerns during an acute manic episode.
3. Which clinical finding is most indicative of Lithium toxicity in a client with bipolar disorder?
A. Mild thirst
B. Coarse tremors and blurred vision
C. Fine hand tremors
D. Occasional nausea
Answer: B
,Rationale: While fine tremors are a common side effect of Lithium, coarse tremors, ataxia,
and blurred vision indicate advanced toxicity. The nurse must recognize these signs as a
medical emergency requiring immediate serum level testing. Failure to identify these
symptoms could lead to seizures, coma, or permanent neurological damage.
4. A client is admitted for Alcohol Withdrawal Syndrome. Which assessment finding indicates
a need for immediate intervention with IV benzodiazepines?
A. Diaphoresis and anxiety
B. Mild hand tremors
C. Tachycardia and visual hallucinations
D. Report of a headache
Answer: C
Rationale: Tachycardia combined with hallucinations suggests the progression into
Delirium Tremens, a life-threatening stage of withdrawal. Immediate pharmacological
intervention is necessary to prevent seizures and cardiovascular collapse. Monitoring vital
signs and mental status is critical during the first 48 to 72 hours of cessation.
5. An adolescent client is hospitalized with Anorexia Nervosa. Which vital sign change most
likely indicates a need for hospitalization?
A. Respiratory rate of 16 breaths per minute
B. Blood pressure of 110/70 mmHg
C. Body temperature of 98.2°F
D. Heart rate of 38 beats per minute
Answer: D
Rationale: Severe bradycardia, such as a heart rate below 40 bpm, indicates significant
cardiovascular compromise in clients with anorexia. This physiological instability requires
inpatient medical stabilization to prevent sudden cardiac arrest. Other stable vital signs do
not negate the emergency status of the heart rate.
6. A nurse is teaching a client about a newly prescribed Monoamine Oxidase Inhibitor
(MAOI). Which food choice should the nurse instruct the client to avoid?
A. Fresh chicken and rice
B. Steamed broccoli and carrots
C. Aged cheddar cheese and salami
D. Whole grain bread and butter
Answer: C
, Rationale: MAOIs interact with tyramine-rich foods like aged cheese and cured meats to
cause a hypertensive crisis. This interaction results in massive norepinephrine release,
potentially causing stroke or organ damage. Education must emphasize strict dietary
adherence to prevent this life-threatening complication.
7. A client with Borderline Personality Disorder uses ‘splitting’ when interacting with staff.
How should the nurse respond?
A. Agree with the client that certain staff members are better than others
B. Maintain open communication with the treatment team to ensure consistent limits
C. Encourage the client to discuss feelings with the staff member they dislike
D. Offer the client extra privileges to build rapport
Answer: B
Rationale: Splitting is a defense mechanism where the client perceives others as all good
or all bad. This behavior often leads to staff conflict and manipulation within the milieu.
Consistent limit-setting and team communication are essential to provide a stable
therapeutic environment.
8. The nurse is evaluating a client for Serotonin Syndrome. Which symptoms should the nurse
expect to find?
A. Hypotension, bradycardia, and lethargy
B. Increased appetite, weight gain, and somnolence
C. Constipation, urinary retention, and dry mouth
D. Muscle rigidity, fever, and tachycardia
Answer: D
Rationale: Serotonin syndrome is an over-activation of serotonin receptors characterized
by autonomic instability and neuromuscular hyperactivity. Clinical manifestations include
high fever, tachycardia, and hyperreflexia or rigidity. This condition is often precipitated by
the combination of multiple serotonergic agents.
9. A client has been prescribed Haloperidol. The nurse observes the client has a high fever,
muscle stiffness, and unstable blood pressure. Which complication does the nurse suspect?
A. Tardive Dyskinesia
B. Acute Dystonia
C. Pseudoparkinsonism
D. Neuroleptic Malignant Syndrome (NMS)
Answer: D
