NUR 2459 Final Exam Actual Exam V3 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A nurse is performing a mental status examination (MSE) on a newly admitted client.
Which component of the MSE is the nurse evaluating when asking the client to interpret the
proverb ‘Don’t cry over spilled milk’?
A. Memory
B. Orientation
C. Abstract reasoning
D. Attention span
Answer: C
Rationale: Abstract reasoning is the ability to interpret information that is not literal, such
as proverbs. The nurse assesses this to determine the client’s cognitive processing level.
This is a standard part of a comprehensive mental status examination.
2. A client is in the orientation phase of the therapeutic relationship. Which of the following
actions should the nurse prioritize during this phase?
A. Promoting the client’s problem-solving skills
B. Establishing the boundaries of the relationship
C. Overcoming resistance to therapy
D. Evaluating the progress toward goals
Answer: B
Rationale: The orientation phase focuses on establishing trust and defining the parameters
of the relationship. It is during this time that the nurse and client set the contract and
identify goals. Boundaries must be clearly stated to ensure a professional and safe
environment.
3. A nurse is caring for a client with schizophrenia who reports hearing voices telling them
that the food is poisoned. Which response by the nurse is most therapeutic?
A. ‘The food is perfectly safe; I ate some myself earlier.’
B. ‘Why do you think someone would want to poison your food?’
C. ‘I don’t hear the voices, but I understand that they are real to you.’
D. ‘You are safe here, so the voices cannot be right.’
Answer: C
,Rationale: The nurse should acknowledge the client’s feelings without reinforcing the
hallucination. Presenting reality in a non-confrontational way helps build trust. It is
important to avoid arguing with the client about their false perceptions.
4. A client is prescribed Lithium carbonate for bipolar disorder. Which of the following
instructions should the nurse include in the teaching plan?
A. Limit sodium intake to prevent toxicity.
B. Take the medication on an empty stomach.
C. Stop taking the medication if you feel better.
D. Maintain a consistent fluid and salt intake.
Answer: D
Rationale: Lithium is a salt, and its levels are inversely related to sodium levels in the
body. If sodium intake drops or fluid loss increases, lithium levels can rise to toxic levels.
Consistent intake of both is vital for maintaining a therapeutic range.
5. A nurse is assessing a client for potential suicide risk. Which of the following statements by
the client represents the highest level of lethality?
A. ‘I wish I didn’t have to wake up tomorrow.’
B. ‘My family would be better off without me.’
C. ‘Sometimes I think about taking all my pills at once.’
D. ‘I have a loaded gun in my nightstand at home.’
Answer: D
Rationale: A specific plan with a highly lethal method and immediate access to that
method indicates the highest risk. Assessing the plan, method, and access is critical for
safety. The nurse must implement immediate 1-to-1 observation for this client.
6. Which of the following findings should a nurse expect in a client experiencing a panic
attack?
A. Decreased heart rate
B. Depersonalization
C. Increased appetite
D. Relaxed muscle tone
Answer: B
Rationale: Panic attacks often involve a sense of unreality or being detached from oneself,
known as depersonalization. Physical symptoms typically include tachycardia and
, palpitations rather than a decreased heart rate. The client may also experience a fear of
dying or losing control.
7. A client is prescribed phenelzine (an MAOI). The nurse should instruct the client to avoid
which of the following foods to prevent a hypertensive crisis?
A. Cottage cheese
B. Aged cheddar cheese
C. Fresh green beans
D. Grilled chicken breast
Answer: B
Rationale: MAOIs interact with tyramine-rich foods, such as aged cheeses, cured meats,
and red wine. This interaction can lead to a dangerous spike in blood pressure. Education
on a low-tyramine diet is a primary safety intervention for clients on this class of
medication.
8. A nurse is caring for a client with anorexia nervosa. Which of the following is the priority
nursing intervention?
A. Monitoring the client’s weight and vital signs daily.
B. Encouraging the client to express feelings about body image.
C. Teaching the client about healthy eating habits.
D. Attending family therapy sessions with the client.
Answer: A
Rationale: In the acute phase of anorexia nervosa, physiological stability is the priority.
Monitoring weight and vital signs helps detect life-threatening complications like
electrolyte imbalances or cardiac arrhythmias. Psychological interventions follow once the
client is physically stable.
9. A client with borderline personality disorder is using ‘splitting’ behavior. How is this
behavior best described?
A. Viewing staff members as either all good or all bad.
B. Developing physical symptoms to avoid conflict.
C. Returning to an earlier developmental stage.
D. Justifying unreasonable actions with logic.
Answer: A
Rationale: Splitting is a common defense mechanism where the individual cannot
integrate positive and negative qualities of others. This often leads to conflict within the
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A nurse is performing a mental status examination (MSE) on a newly admitted client.
Which component of the MSE is the nurse evaluating when asking the client to interpret the
proverb ‘Don’t cry over spilled milk’?
A. Memory
B. Orientation
C. Abstract reasoning
D. Attention span
Answer: C
Rationale: Abstract reasoning is the ability to interpret information that is not literal, such
as proverbs. The nurse assesses this to determine the client’s cognitive processing level.
This is a standard part of a comprehensive mental status examination.
2. A client is in the orientation phase of the therapeutic relationship. Which of the following
actions should the nurse prioritize during this phase?
A. Promoting the client’s problem-solving skills
B. Establishing the boundaries of the relationship
C. Overcoming resistance to therapy
D. Evaluating the progress toward goals
Answer: B
Rationale: The orientation phase focuses on establishing trust and defining the parameters
of the relationship. It is during this time that the nurse and client set the contract and
identify goals. Boundaries must be clearly stated to ensure a professional and safe
environment.
3. A nurse is caring for a client with schizophrenia who reports hearing voices telling them
that the food is poisoned. Which response by the nurse is most therapeutic?
A. ‘The food is perfectly safe; I ate some myself earlier.’
B. ‘Why do you think someone would want to poison your food?’
C. ‘I don’t hear the voices, but I understand that they are real to you.’
D. ‘You are safe here, so the voices cannot be right.’
Answer: C
,Rationale: The nurse should acknowledge the client’s feelings without reinforcing the
hallucination. Presenting reality in a non-confrontational way helps build trust. It is
important to avoid arguing with the client about their false perceptions.
4. A client is prescribed Lithium carbonate for bipolar disorder. Which of the following
instructions should the nurse include in the teaching plan?
A. Limit sodium intake to prevent toxicity.
B. Take the medication on an empty stomach.
C. Stop taking the medication if you feel better.
D. Maintain a consistent fluid and salt intake.
Answer: D
Rationale: Lithium is a salt, and its levels are inversely related to sodium levels in the
body. If sodium intake drops or fluid loss increases, lithium levels can rise to toxic levels.
Consistent intake of both is vital for maintaining a therapeutic range.
5. A nurse is assessing a client for potential suicide risk. Which of the following statements by
the client represents the highest level of lethality?
A. ‘I wish I didn’t have to wake up tomorrow.’
B. ‘My family would be better off without me.’
C. ‘Sometimes I think about taking all my pills at once.’
D. ‘I have a loaded gun in my nightstand at home.’
Answer: D
Rationale: A specific plan with a highly lethal method and immediate access to that
method indicates the highest risk. Assessing the plan, method, and access is critical for
safety. The nurse must implement immediate 1-to-1 observation for this client.
6. Which of the following findings should a nurse expect in a client experiencing a panic
attack?
A. Decreased heart rate
B. Depersonalization
C. Increased appetite
D. Relaxed muscle tone
Answer: B
Rationale: Panic attacks often involve a sense of unreality or being detached from oneself,
known as depersonalization. Physical symptoms typically include tachycardia and
, palpitations rather than a decreased heart rate. The client may also experience a fear of
dying or losing control.
7. A client is prescribed phenelzine (an MAOI). The nurse should instruct the client to avoid
which of the following foods to prevent a hypertensive crisis?
A. Cottage cheese
B. Aged cheddar cheese
C. Fresh green beans
D. Grilled chicken breast
Answer: B
Rationale: MAOIs interact with tyramine-rich foods, such as aged cheeses, cured meats,
and red wine. This interaction can lead to a dangerous spike in blood pressure. Education
on a low-tyramine diet is a primary safety intervention for clients on this class of
medication.
8. A nurse is caring for a client with anorexia nervosa. Which of the following is the priority
nursing intervention?
A. Monitoring the client’s weight and vital signs daily.
B. Encouraging the client to express feelings about body image.
C. Teaching the client about healthy eating habits.
D. Attending family therapy sessions with the client.
Answer: A
Rationale: In the acute phase of anorexia nervosa, physiological stability is the priority.
Monitoring weight and vital signs helps detect life-threatening complications like
electrolyte imbalances or cardiac arrhythmias. Psychological interventions follow once the
client is physically stable.
9. A client with borderline personality disorder is using ‘splitting’ behavior. How is this
behavior best described?
A. Viewing staff members as either all good or all bad.
B. Developing physical symptoms to avoid conflict.
C. Returning to an earlier developmental stage.
D. Justifying unreasonable actions with logic.
Answer: A
Rationale: Splitting is a common defense mechanism where the individual cannot
integrate positive and negative qualities of others. This often leads to conflict within the
