NUR 2459 Final Exam Actual Exam V3 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A client with schizophrenia starts to experience auditory hallucinations and becomes
increasingly agitated. Which initial nursing intervention is most appropriate?
A. Acknowledge the client’s experience and provide a calm, low-stimulation environment.
B. Tell the client that the voices are not real and to ignore them.
C. Request a PRN prescription for a physical restraint.
D. Leave the client alone in their room to de-escalate without interference.
Answer: A
Rationale: Validating the client’s feelings while acknowledging that the nurse does not
hear the voices helps build trust without reinforcing the hallucination. Reducing
environmental stimuli is a key intervention to prevent further agitation and sensory
overload in a psychotic client. Safety and rapport are prioritized before considering more
restrictive measures like restraints.
2. A nurse is caring for a client with Bipolar I Disorder who is in an acute manic phase. The
client is pacing the halls and interrupting others. Which diet selection is best for this client?
A. A cheeseburger, an apple, and a milk carton.
B. Chicken soup, crackers, and hot tea.
C. Steak, baked potato, and a side salad.
D. Spaghetti with meatballs and a slice of cake.
Answer: A
Rationale: Clients in an acute manic phase often have high energy expenditure and cannot
sit down long enough to eat a full meal. Providing ‘finger foods’ that are high in protein and
calories allows the client to eat while on the move, ensuring adequate nutrition. This
approach addresses the physical safety and nutritional needs of a client with hyperactive
behavior.
3. A nurse is reviewing the laboratory results of a client taking Lithium carbonate for Bipolar
Disorder. The lithium level is 1.8 mEq/L. What is the nurse’s priority action?
A. Administer the next scheduled dose as prescribed.
B. Increase the client’s fluid intake and document the findings.
C. Request a repeat lab draw to confirm the result.
D. Hold the medication and notify the healthcare provider immediately.
,Answer: D
Rationale: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6 to 1.2 mEq/L)
and indicates moderate toxicity. The nurse must prioritize patient safety by holding the
dose to prevent worsening toxicity, which can lead to seizures or death. Notification of the
provider is essential for potential medical interventions such as gastric lavage or
hemodialysis.
4. A client is admitted to the psychiatric unit for Major Depressive Disorder. During the
assessment, the client states, ‘I don’t have to worry about my problems much longer.’ How
should the nurse respond?
A. ‘Are you thinking of harming yourself or ending your life?’
B. ‘It is good to hear that you are feeling more optimistic today.’
C. ‘Tell me more about the problems you are facing right now.’
D. ‘Everyone goes through hard times; things will get better.’
Answer: A
Rationale: The client’s statement is a covert clue of suicidal ideation, which requires a
direct and immediate assessment of suicide risk. Asking directly about suicidal intent is the
standard of care for ensuring patient safety in mental health nursing. This intervention
allows the nurse to implement necessary precautions if the client confirms they have a plan
or intent.
5. A client with Borderline Personality Disorder is splitting the staff by telling a nurse, ‘The
night nurse is so mean, but you are the only one who cares about me.’ Which response by the
nurse is therapeutic?
A. ‘I am glad you trust me, I will talk to the night nurse for you.’
B. ‘Why do you think the night nurse is being mean to you?’
C. ‘We all work as a team here to provide your care consistently.’
D. ‘I agree, the night nurse can be quite strict sometimes.’
Answer: C
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as all good or all bad. The nurse must maintain
professional boundaries and reinforce the concept of a unified treatment team to prevent
manipulation. Neutrality and consistency among staff members are vital to the successful
management of personality disorders.
6. A client is prescribed Phenelzine (Nardil), an MAOI. Which food item should the nurse
instruct the client to avoid to prevent a hypertensive crisis?
A. Fresh apples and oranges.
, B. Aged cheddar cheese and pepperoni pizza.
C. Grilled chicken breast and white rice.
D. Cottage cheese and scrambled eggs.
Answer: B
Rationale: MAOIs interact with tyramine-rich foods, which can lead to a dangerous
increase in blood pressure known as a hypertensive crisis. Aged cheeses, cured meats, and
fermented products are high in tyramine and must be strictly avoided by clients on this
medication. Patient education is a critical nursing responsibility to prevent life-threatening
adverse reactions.
7. A client is experiencing an acute panic attack. Which nursing action is the most effective
during the peak of the attack?
A. Teach the client new coping strategies and relaxation techniques.
B. Stay with the client and use short, simple sentences.
C. Ask the client to explain what triggered the panic attack.
D. Encourage the client to go to the gym to burn off excess energy.
Answer: B
Rationale: During a panic attack, the client’s ability to process information is severely
diminished, making complex teaching ineffective. Staying with the client provides a sense
of security and safety, which is the immediate priority. Short, simple sentences are
necessary because the client’s perceptual field is narrowed to the point of being unable to
follow detailed instructions.
8. A nurse is caring for a client with Anorexia Nervosa. What is the priority nursing diagnosis
during the initial phase of treatment?
A. Disturbed Body Image.
B. Low Self-Esteem.
C. Imbalanced Nutrition: Less Than Body Requirements.
D. Social Isolation.
Answer: C
Rationale: While all the diagnoses listed are relevant to Anorexia Nervosa, the
physiological stability of the client is always the priority. Severe malnutrition can lead to
life-threatening complications such as cardiac arrhythmias and electrolyte imbalances.
Initial treatment focuses on weight restoration and stabilizing the client’s physical health
before addressing psychological issues.
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A client with schizophrenia starts to experience auditory hallucinations and becomes
increasingly agitated. Which initial nursing intervention is most appropriate?
A. Acknowledge the client’s experience and provide a calm, low-stimulation environment.
B. Tell the client that the voices are not real and to ignore them.
C. Request a PRN prescription for a physical restraint.
D. Leave the client alone in their room to de-escalate without interference.
Answer: A
Rationale: Validating the client’s feelings while acknowledging that the nurse does not
hear the voices helps build trust without reinforcing the hallucination. Reducing
environmental stimuli is a key intervention to prevent further agitation and sensory
overload in a psychotic client. Safety and rapport are prioritized before considering more
restrictive measures like restraints.
2. A nurse is caring for a client with Bipolar I Disorder who is in an acute manic phase. The
client is pacing the halls and interrupting others. Which diet selection is best for this client?
A. A cheeseburger, an apple, and a milk carton.
B. Chicken soup, crackers, and hot tea.
C. Steak, baked potato, and a side salad.
D. Spaghetti with meatballs and a slice of cake.
Answer: A
Rationale: Clients in an acute manic phase often have high energy expenditure and cannot
sit down long enough to eat a full meal. Providing ‘finger foods’ that are high in protein and
calories allows the client to eat while on the move, ensuring adequate nutrition. This
approach addresses the physical safety and nutritional needs of a client with hyperactive
behavior.
3. A nurse is reviewing the laboratory results of a client taking Lithium carbonate for Bipolar
Disorder. The lithium level is 1.8 mEq/L. What is the nurse’s priority action?
A. Administer the next scheduled dose as prescribed.
B. Increase the client’s fluid intake and document the findings.
C. Request a repeat lab draw to confirm the result.
D. Hold the medication and notify the healthcare provider immediately.
,Answer: D
Rationale: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6 to 1.2 mEq/L)
and indicates moderate toxicity. The nurse must prioritize patient safety by holding the
dose to prevent worsening toxicity, which can lead to seizures or death. Notification of the
provider is essential for potential medical interventions such as gastric lavage or
hemodialysis.
4. A client is admitted to the psychiatric unit for Major Depressive Disorder. During the
assessment, the client states, ‘I don’t have to worry about my problems much longer.’ How
should the nurse respond?
A. ‘Are you thinking of harming yourself or ending your life?’
B. ‘It is good to hear that you are feeling more optimistic today.’
C. ‘Tell me more about the problems you are facing right now.’
D. ‘Everyone goes through hard times; things will get better.’
Answer: A
Rationale: The client’s statement is a covert clue of suicidal ideation, which requires a
direct and immediate assessment of suicide risk. Asking directly about suicidal intent is the
standard of care for ensuring patient safety in mental health nursing. This intervention
allows the nurse to implement necessary precautions if the client confirms they have a plan
or intent.
5. A client with Borderline Personality Disorder is splitting the staff by telling a nurse, ‘The
night nurse is so mean, but you are the only one who cares about me.’ Which response by the
nurse is therapeutic?
A. ‘I am glad you trust me, I will talk to the night nurse for you.’
B. ‘Why do you think the night nurse is being mean to you?’
C. ‘We all work as a team here to provide your care consistently.’
D. ‘I agree, the night nurse can be quite strict sometimes.’
Answer: C
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as all good or all bad. The nurse must maintain
professional boundaries and reinforce the concept of a unified treatment team to prevent
manipulation. Neutrality and consistency among staff members are vital to the successful
management of personality disorders.
6. A client is prescribed Phenelzine (Nardil), an MAOI. Which food item should the nurse
instruct the client to avoid to prevent a hypertensive crisis?
A. Fresh apples and oranges.
, B. Aged cheddar cheese and pepperoni pizza.
C. Grilled chicken breast and white rice.
D. Cottage cheese and scrambled eggs.
Answer: B
Rationale: MAOIs interact with tyramine-rich foods, which can lead to a dangerous
increase in blood pressure known as a hypertensive crisis. Aged cheeses, cured meats, and
fermented products are high in tyramine and must be strictly avoided by clients on this
medication. Patient education is a critical nursing responsibility to prevent life-threatening
adverse reactions.
7. A client is experiencing an acute panic attack. Which nursing action is the most effective
during the peak of the attack?
A. Teach the client new coping strategies and relaxation techniques.
B. Stay with the client and use short, simple sentences.
C. Ask the client to explain what triggered the panic attack.
D. Encourage the client to go to the gym to burn off excess energy.
Answer: B
Rationale: During a panic attack, the client’s ability to process information is severely
diminished, making complex teaching ineffective. Staying with the client provides a sense
of security and safety, which is the immediate priority. Short, simple sentences are
necessary because the client’s perceptual field is narrowed to the point of being unable to
follow detailed instructions.
8. A nurse is caring for a client with Anorexia Nervosa. What is the priority nursing diagnosis
during the initial phase of treatment?
A. Disturbed Body Image.
B. Low Self-Esteem.
C. Imbalanced Nutrition: Less Than Body Requirements.
D. Social Isolation.
Answer: C
Rationale: While all the diagnoses listed are relevant to Anorexia Nervosa, the
physiological stability of the client is always the priority. Severe malnutrition can lead to
life-threatening complications such as cardiac arrhythmias and electrolyte imbalances.
Initial treatment focuses on weight restoration and stabilizing the client’s physical health
before addressing psychological issues.
