NUR 2459 Final Exam Actual Exam V2 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A nurse is caring for a client with Bipolar Disorder who is experiencing acute mania and
taking Lithium. The client reports blurred vision, severe diarrhea, and persistent nausea.
Which action should the nurse take first?
A. Administer the next scheduled dose of Lithium.
B. Encourage the client to increase fluid intake.
C. Document the findings as expected side effects.
D. Hold the medication and notify the healthcare provider.
Answer: D
Rationale: These symptoms are classic indicators of Lithium toxicity, which is a medical
emergency. The nurse must immediately stop the medication to prevent further toxicity
and potential organ damage. Following the hold, a serum lithium level must be obtained to
determine the severity of the situation.
2. A client is admitted to the psychiatric unit after a suicide attempt. Which question is most
important for the nurse to ask during the initial assessment?
A. Why did you try to hurt yourself today?
B. Do you have a plan to harm yourself now?
C. How long have you been feeling depressed?
D. Does your family have a history of mental illness?
Answer: B
Rationale: Assessing for current suicidal ideation and a specific plan is the highest priority
for ensuring patient safety. This direct question helps determine the immediate level of risk
and the necessary level of observation. Safety interventions, such as one-to-one
observation, are implemented based on this critical information.
3. A nurse is using therapeutic communication with a client who is depressed. The client
states, ‘Nothing ever goes right for me.’ Which response by the nurse is most therapeutic?
A. I am sure things will get better soon.
B. Why do you feel that way?
C. It sounds like you are feeling very frustrated right now.
D. You should try to think more positively about your life.
,Answer: C
Rationale: This response uses the technique of reflection to acknowledge the client’s
feelings without judgment. It validates the client’s emotional experience and encourages
further expression of their thoughts. Avoiding ‘why’ questions and false reassurances is
essential for maintaining a therapeutic relationship.
4. A client with Schizophrenia is heard talking to someone who is not there and appears
agitated. What is the priority nursing intervention?
A. Tell the client that there is no one else in the room.
B. Ask the client, ‘What are the voices telling you to do?’
C. Administer a PRN sedative immediately.
D. Leave the client alone to provide some privacy.
Answer: B
Rationale: It is crucial to assess for command hallucinations, which may instruct the client
to harm themselves or others. Identifying the content of the hallucination allows the nurse
to implement appropriate safety measures. Once safety is assessed, the nurse can then
focus on grounding techniques and reality orientation.
5. A nurse observes a client with Borderline Personality Disorder being very friendly with one
nurse while complaining bitterly about another nurse. This behavior is known as:
A. Reaction formation
B. Splitting
C. Projection
D. Undoing
Answer: B
Rationale: Splitting is a common defense mechanism where individuals perceive others as
either all good or all bad. This behavior often creates conflict among the staff and
destabilizes the treatment environment. Consistency among the treatment team and firm
limit setting are necessary to manage this behavior effectively.
6. A client is experiencing alcohol withdrawal and begins to show signs of autonomic
hyperactivity, including tachycardia and diaphoresis. Which medication should the nurse
expect to administer?
A. Disulfiram
B. Methadone
C. Haloperidol
, D. Lorazepam
Answer: D
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms and preventing seizures. They act on the GABA receptors to
provide a sedative effect that counteracts the CNS hyperexcitability. Monitoring the client
with a standardized tool like the CIWA-Ar scale is essential during this process.
7. A client taking a Monoamine Oxidase Inhibitor (MAOI) for depression must be educated to
avoid which of the following foods?
A. Aged cheeses and pepperoni
B. Fresh green salads
C. Whole grain breads
D. Fresh oranges and apples
Answer: A
Rationale: Foods high in tyramine, such as aged cheeses and cured meats, can trigger a
hypertensive crisis in patients taking MAOIs. A hypertensive crisis is a life-threatening
elevation in blood pressure that can lead to a stroke. The nurse must provide a
comprehensive list of restricted foods and emphasize the importance of dietary
compliance.
8. Which of the following is a legal requirement for the involuntary admission of a client to a
psychiatric facility?
A. The client must be a danger to themselves or others.
B. The client must have a diagnosed personality disorder.
C. The client must agree to all proposed treatments.
D. The family must provide written consent for the admission.
Answer: A
Rationale: Involuntary admission is based on the principle of protecting the individual and
the public from harm. Criteria usually include being a danger to self, a danger to others, or
being unable to provide for basic needs due to mental illness. Even when admitted
involuntarily, clients retain certain rights, such as the right to refuse medication in non-
emergencies.
9. A nurse is caring for a client with Post-Traumatic Stress Disorder (PTSD) who is
experiencing a flashback. Which action is most appropriate?
A. Touch the client’s shoulder to get their attention.
B. Speak in a loud voice to snap them out of it.
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A nurse is caring for a client with Bipolar Disorder who is experiencing acute mania and
taking Lithium. The client reports blurred vision, severe diarrhea, and persistent nausea.
Which action should the nurse take first?
A. Administer the next scheduled dose of Lithium.
B. Encourage the client to increase fluid intake.
C. Document the findings as expected side effects.
D. Hold the medication and notify the healthcare provider.
Answer: D
Rationale: These symptoms are classic indicators of Lithium toxicity, which is a medical
emergency. The nurse must immediately stop the medication to prevent further toxicity
and potential organ damage. Following the hold, a serum lithium level must be obtained to
determine the severity of the situation.
2. A client is admitted to the psychiatric unit after a suicide attempt. Which question is most
important for the nurse to ask during the initial assessment?
A. Why did you try to hurt yourself today?
B. Do you have a plan to harm yourself now?
C. How long have you been feeling depressed?
D. Does your family have a history of mental illness?
Answer: B
Rationale: Assessing for current suicidal ideation and a specific plan is the highest priority
for ensuring patient safety. This direct question helps determine the immediate level of risk
and the necessary level of observation. Safety interventions, such as one-to-one
observation, are implemented based on this critical information.
3. A nurse is using therapeutic communication with a client who is depressed. The client
states, ‘Nothing ever goes right for me.’ Which response by the nurse is most therapeutic?
A. I am sure things will get better soon.
B. Why do you feel that way?
C. It sounds like you are feeling very frustrated right now.
D. You should try to think more positively about your life.
,Answer: C
Rationale: This response uses the technique of reflection to acknowledge the client’s
feelings without judgment. It validates the client’s emotional experience and encourages
further expression of their thoughts. Avoiding ‘why’ questions and false reassurances is
essential for maintaining a therapeutic relationship.
4. A client with Schizophrenia is heard talking to someone who is not there and appears
agitated. What is the priority nursing intervention?
A. Tell the client that there is no one else in the room.
B. Ask the client, ‘What are the voices telling you to do?’
C. Administer a PRN sedative immediately.
D. Leave the client alone to provide some privacy.
Answer: B
Rationale: It is crucial to assess for command hallucinations, which may instruct the client
to harm themselves or others. Identifying the content of the hallucination allows the nurse
to implement appropriate safety measures. Once safety is assessed, the nurse can then
focus on grounding techniques and reality orientation.
5. A nurse observes a client with Borderline Personality Disorder being very friendly with one
nurse while complaining bitterly about another nurse. This behavior is known as:
A. Reaction formation
B. Splitting
C. Projection
D. Undoing
Answer: B
Rationale: Splitting is a common defense mechanism where individuals perceive others as
either all good or all bad. This behavior often creates conflict among the staff and
destabilizes the treatment environment. Consistency among the treatment team and firm
limit setting are necessary to manage this behavior effectively.
6. A client is experiencing alcohol withdrawal and begins to show signs of autonomic
hyperactivity, including tachycardia and diaphoresis. Which medication should the nurse
expect to administer?
A. Disulfiram
B. Methadone
C. Haloperidol
, D. Lorazepam
Answer: D
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms and preventing seizures. They act on the GABA receptors to
provide a sedative effect that counteracts the CNS hyperexcitability. Monitoring the client
with a standardized tool like the CIWA-Ar scale is essential during this process.
7. A client taking a Monoamine Oxidase Inhibitor (MAOI) for depression must be educated to
avoid which of the following foods?
A. Aged cheeses and pepperoni
B. Fresh green salads
C. Whole grain breads
D. Fresh oranges and apples
Answer: A
Rationale: Foods high in tyramine, such as aged cheeses and cured meats, can trigger a
hypertensive crisis in patients taking MAOIs. A hypertensive crisis is a life-threatening
elevation in blood pressure that can lead to a stroke. The nurse must provide a
comprehensive list of restricted foods and emphasize the importance of dietary
compliance.
8. Which of the following is a legal requirement for the involuntary admission of a client to a
psychiatric facility?
A. The client must be a danger to themselves or others.
B. The client must have a diagnosed personality disorder.
C. The client must agree to all proposed treatments.
D. The family must provide written consent for the admission.
Answer: A
Rationale: Involuntary admission is based on the principle of protecting the individual and
the public from harm. Criteria usually include being a danger to self, a danger to others, or
being unable to provide for basic needs due to mental illness. Even when admitted
involuntarily, clients retain certain rights, such as the right to refuse medication in non-
emergencies.
9. A nurse is caring for a client with Post-Traumatic Stress Disorder (PTSD) who is
experiencing a flashback. Which action is most appropriate?
A. Touch the client’s shoulder to get their attention.
B. Speak in a loud voice to snap them out of it.
