NUR 2459 Exam 4 Actual Exam V2 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A patient with schizophrenia is hearing voices telling them to ‘hurt the nurse.’ Which action
should the nurse take first?
A. Place the patient in a seclusion room immediately.
B. Administer a PRN dose of an antipsychotic medication.
C. Ask the patient directly about the content of the hallucinations.
D. Tell the patient that the voices are not real and to ignore them.
Answer: C
Rationale: Assessment is the priority when a patient experiences command hallucinations
to determine the risk of violence. By asking about the content, the nurse identifies the level
of threat to safety for the patient and others. This action allows the nurse to implement
appropriate safety precautions based on the specific commands being heard.
2. A patient taking Lithium Carbonate for Bipolar Disorder reports blurred vision and severe
diarrhea. The nurse notes the patient is tremors and appears confused. What is the priority
nursing action?
A. Withhold the medication and notify the healthcare provider.
B. Administer the next scheduled dose of Lithium.
C. Encourage the patient to increase their fluid intake.
D. Request a stat ECG to check for cardiac arrhythmias.
Answer: A
Rationale: The symptoms described—blurred vision, diarrhea, tremors, and confusion—
are classic signs of lithium toxicity. The nurse must stop the medication immediately to
prevent further toxicity and potential organ damage. Following the hold, the provider
should be notified to order a serum lithium level and provide further medical intervention.
3. Which assessment finding in a patient taking Clozapine requires immediate intervention by
the nurse?
A. A sore throat and a temperature of 101.2°F (38.4°C).
B. A weight gain of 2 pounds in one week.
C. Complaints of dry mouth and constipation.
D. Drowsiness when first starting the medication.
,Answer: A
Rationale: Clozapine is associated with a risk of agranulocytosis, which is a dangerous
drop in white blood cell count. Fever and sore throat are early indicators of infection that
may result from this condition. Immediate blood work is required to assess the Absolute
Neutrophil Count (ANC) before continuing the medication.
4. A nurse is caring for a patient who is experiencing a manic episode. Which meal choice is
most appropriate for this patient?
A. A bowl of hot soup and a side salad.
B. A cheeseburger and a banana.
C. Spaghetti with meatballs and a breadstick.
D. Steak with a baked potato and green beans.
Answer: B
Rationale: Patients in a manic state often have high energy levels and cannot sit still long
enough to eat a full meal. ‘Finger foods’ that are high in protein and calories allow the
patient to eat while moving around the unit. A cheeseburger and banana are easy to hold
and provide necessary nutrients for the patient’s high metabolic rate.
5. A patient with Borderline Personality Disorder tells a nurse, ‘You are the only one who
cares. The night nurse is mean and incompetent.’ This is an example of which defense
mechanism?
A. Reaction Formation
B. Projective Identification
C. Intellectualization
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in individuals with Borderline
Personality Disorder where they categorize people as either ‘all good’ or ‘all bad.’ This
behavior often leads to conflict among the healthcare team as the patient tries to
manipulate staff members against each other. Consistent communication among the
nursing staff is essential to manage this behavior effectively.
6. A nurse is assessing a patient for alcohol withdrawal. Which symptom indicates the need
for immediate medical intervention?
A. Mild tremors of the hands.
B. Generalized tonic-clonic seizures.
C. Tachycardia and diaphoresis.
, D. Report of feeling anxious and irritable.
Answer: B
Rationale: Seizures are a severe and potentially life-threatening complication of alcohol
withdrawal, usually occurring within 6 to 48 hours after the last drink. They represent a
significant physiological instability that requires immediate benzodiazepine administration
and safety precautions. While tremors and tachycardia are signs of withdrawal, seizures
indicate a progression toward delirium tremens.
7. An elderly patient with dementia becomes agitated and aggressive toward staff in the
evening. What is the best initial nursing intervention?
A. Administer a dose of Haloperidol as prescribed.
B. Apply soft wrist restraints to prevent injury.
C. Correct the patient’s orientation to time and place firmly.
D. Reduce environmental stimuli and provide soft lighting.
Answer: D
Rationale: This behavior is known as ‘sundowning,’ where confusion and agitation worsen
in the late afternoon and evening. Reducing environmental stimuli helps to calm the patient
without the use of chemical or physical restraints. Maintaining a calm, low-stress
environment is the least restrictive and often most effective first step in behavioral
management.
8. A patient with Anorexia Nervosa has a BMI of 15 and is being admitted for nutritional
stabilization. Which complication should the nurse monitor for during the first week of
treatment?
A. Hyperglycemia
B. Refeeding Syndrome
C. Elevated liver enzymes
D. Hypernatremia
Answer: B
Rationale: Refeeding syndrome occurs when a severely malnourished patient receives
nutritional support, leading to dangerous shifts in electrolytes like phosphorus,
magnesium, and potassium. This can lead to cardiac failure and respiratory distress if not
monitored closely. The nurse must ensure slow reintroduction of calories and frequent lab
checks.
9. Which statement by a patient starting Fluoxetine (Prozac) indicates a need for further
teaching?
A. ‘I will report any increased suicidal thoughts to my doctor.’
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A patient with schizophrenia is hearing voices telling them to ‘hurt the nurse.’ Which action
should the nurse take first?
A. Place the patient in a seclusion room immediately.
B. Administer a PRN dose of an antipsychotic medication.
C. Ask the patient directly about the content of the hallucinations.
D. Tell the patient that the voices are not real and to ignore them.
Answer: C
Rationale: Assessment is the priority when a patient experiences command hallucinations
to determine the risk of violence. By asking about the content, the nurse identifies the level
of threat to safety for the patient and others. This action allows the nurse to implement
appropriate safety precautions based on the specific commands being heard.
2. A patient taking Lithium Carbonate for Bipolar Disorder reports blurred vision and severe
diarrhea. The nurse notes the patient is tremors and appears confused. What is the priority
nursing action?
A. Withhold the medication and notify the healthcare provider.
B. Administer the next scheduled dose of Lithium.
C. Encourage the patient to increase their fluid intake.
D. Request a stat ECG to check for cardiac arrhythmias.
Answer: A
Rationale: The symptoms described—blurred vision, diarrhea, tremors, and confusion—
are classic signs of lithium toxicity. The nurse must stop the medication immediately to
prevent further toxicity and potential organ damage. Following the hold, the provider
should be notified to order a serum lithium level and provide further medical intervention.
3. Which assessment finding in a patient taking Clozapine requires immediate intervention by
the nurse?
A. A sore throat and a temperature of 101.2°F (38.4°C).
B. A weight gain of 2 pounds in one week.
C. Complaints of dry mouth and constipation.
D. Drowsiness when first starting the medication.
,Answer: A
Rationale: Clozapine is associated with a risk of agranulocytosis, which is a dangerous
drop in white blood cell count. Fever and sore throat are early indicators of infection that
may result from this condition. Immediate blood work is required to assess the Absolute
Neutrophil Count (ANC) before continuing the medication.
4. A nurse is caring for a patient who is experiencing a manic episode. Which meal choice is
most appropriate for this patient?
A. A bowl of hot soup and a side salad.
B. A cheeseburger and a banana.
C. Spaghetti with meatballs and a breadstick.
D. Steak with a baked potato and green beans.
Answer: B
Rationale: Patients in a manic state often have high energy levels and cannot sit still long
enough to eat a full meal. ‘Finger foods’ that are high in protein and calories allow the
patient to eat while moving around the unit. A cheeseburger and banana are easy to hold
and provide necessary nutrients for the patient’s high metabolic rate.
5. A patient with Borderline Personality Disorder tells a nurse, ‘You are the only one who
cares. The night nurse is mean and incompetent.’ This is an example of which defense
mechanism?
A. Reaction Formation
B. Projective Identification
C. Intellectualization
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in individuals with Borderline
Personality Disorder where they categorize people as either ‘all good’ or ‘all bad.’ This
behavior often leads to conflict among the healthcare team as the patient tries to
manipulate staff members against each other. Consistent communication among the
nursing staff is essential to manage this behavior effectively.
6. A nurse is assessing a patient for alcohol withdrawal. Which symptom indicates the need
for immediate medical intervention?
A. Mild tremors of the hands.
B. Generalized tonic-clonic seizures.
C. Tachycardia and diaphoresis.
, D. Report of feeling anxious and irritable.
Answer: B
Rationale: Seizures are a severe and potentially life-threatening complication of alcohol
withdrawal, usually occurring within 6 to 48 hours after the last drink. They represent a
significant physiological instability that requires immediate benzodiazepine administration
and safety precautions. While tremors and tachycardia are signs of withdrawal, seizures
indicate a progression toward delirium tremens.
7. An elderly patient with dementia becomes agitated and aggressive toward staff in the
evening. What is the best initial nursing intervention?
A. Administer a dose of Haloperidol as prescribed.
B. Apply soft wrist restraints to prevent injury.
C. Correct the patient’s orientation to time and place firmly.
D. Reduce environmental stimuli and provide soft lighting.
Answer: D
Rationale: This behavior is known as ‘sundowning,’ where confusion and agitation worsen
in the late afternoon and evening. Reducing environmental stimuli helps to calm the patient
without the use of chemical or physical restraints. Maintaining a calm, low-stress
environment is the least restrictive and often most effective first step in behavioral
management.
8. A patient with Anorexia Nervosa has a BMI of 15 and is being admitted for nutritional
stabilization. Which complication should the nurse monitor for during the first week of
treatment?
A. Hyperglycemia
B. Refeeding Syndrome
C. Elevated liver enzymes
D. Hypernatremia
Answer: B
Rationale: Refeeding syndrome occurs when a severely malnourished patient receives
nutritional support, leading to dangerous shifts in electrolytes like phosphorus,
magnesium, and potassium. This can lead to cardiac failure and respiratory distress if not
monitored closely. The nurse must ensure slow reintroduction of calories and frequent lab
checks.
9. Which statement by a patient starting Fluoxetine (Prozac) indicates a need for further
teaching?
A. ‘I will report any increased suicidal thoughts to my doctor.’
