NUR 2459 Final Exam Actual Exam V1 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A patient with bipolar disorder has a lithium level of 2.1 mEq/L. Which clinical finding
should the nurse prioritize?
A. Fine hand tremors and mild nausea
B. Occasional muscle weakness
C. Polyuria and increased thirst
D. Ataxia and blurred vision
Answer: D
Rationale: A lithium level of 2.1 mEq/L indicates severe toxicity that requires immediate
intervention. Ataxia and blurred vision are signs of significant neurological impairment
that precede seizures and coma. The nurse must withhold the dose and notify the provider
to prevent further physiological deterioration.
2. A client with schizophrenia states, ‘The voices are telling me I am a bad person.’ Which
response by the nurse is most therapeutic?
A. ‘Let’s go to the dayroom and watch television together.’
B. ‘The voices are not real and you should ignore them.’
C. ‘Why do you think the voices are saying that?’
D. ‘I do not hear the voices, but I understand they are real to you.’
Answer: D
Rationale: Acknowledging the patient’s experience while presenting reality is a
fundamental technique in managing hallucinations. This approach validates the patient’s
feelings without reinforcing the false perception. It helps build trust and encourages the
patient to discuss their internal experiences safely.
3. A nurse is caring for a client who was just admitted with severe depression and suicidal
ideation. Which action is the priority?
A. Administering a prescribed antidepressant
B. Performing a search of the client’s belongings
C. Encouraging the client to attend group therapy
D. Assessing the client’s sleep patterns
Answer: B
,Rationale: Safety is the highest priority for a patient admitted with suicidal ideation.
Searching belongings ensures that the patient does not have access to harmful items such
as belts, shoelaces, or sharp objects. This immediate intervention provides a secure
environment while a more comprehensive treatment plan is developed.
4. A client is prescribed phenelzine (Nardil). Which food item should the nurse instruct the
client to avoid?
A. Fresh grilled chicken
B. Aged cheddar cheese
C. Steamed green beans
D. Baked white potato
Answer: B
Rationale: Phenelzine is an MAOI that requires a low-tyramine diet to prevent
hypertensive crisis. Aged cheeses are high in tyramine and can lead to a dangerous spike in
blood pressure. The nurse must educate the patient on identifying and avoiding fermented
or cured food products.
5. A patient exhibits muscle rigidity, a temperature of 103°F (39.4°C), and altered
consciousness while on haloperidol. What should the nurse do first?
A. Apply cooling blankets and stop the medication
B. Administer an extra dose of haloperidol
C. Encourage the patient to drink more fluids
D. Document the findings as a common side effect
Answer: A
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening emergency. The nurse must immediately discontinue the antipsychotic
medication and initiate measures to lower the body temperature. Prompt medical
intervention and transfer to an intensive care setting are often necessary for stabilization.
6. Which assessment finding in a patient with anorexia nervosa is the most concerning?
A. Heart rate of 38 beats per minute
B. Amenorrhea for six months
C. Presence of lanugo on the back
D. Preoccupation with food recipes
Answer: A
, Rationale: A heart rate of 38 bpm indicates severe bradycardia, which can lead to cardiac
arrest and death in patients with eating disorders. While lanugo and amenorrhea are
common findings, they are not immediately life-threatening. The nurse must prioritize
cardiovascular stability and prepare for medical stabilization.
7. A client with Borderline Personality Disorder uses ‘splitting’ when talking to staff. How
should the nurse proceed?
A. Avoid talking to the client until they apologize
B. Hold a staff meeting to ensure a consistent approach
C. Agree with the client to prevent an outburst
D. Assign a different nurse to the client daily
Answer: B
Rationale: Splitting involves the patient seeing staff as either ‘all good’ or ‘all bad,’ which
often leads to conflict between team members. A consistent approach across the
multidisciplinary team prevents the patient from manipulating staff and maintains
professional boundaries. Open communication among staff is essential to counteract this
defense mechanism.
8. A nurse is assessing a client for alcohol withdrawal. Which symptom should be monitored
as an early sign?
A. Prolonged periods of sleep
B. Hypotension and bradycardia
C. Fine tremors and tachycardia
D. Increased appetite and lethargy
Answer: C
Rationale: Withdrawal symptoms typically begin 6 to 12 hours after the last drink, with
tremors and increased heart rate being primary early indicators. The nurse uses
assessment tools like the CIWA-Ar scale to quantify the severity of these symptoms.
Prompt recognition allows for timely administration of benzodiazepines to prevent
delirium tremens.
9. What is the primary goal of the ‘working phase’ in a therapeutic nurse-client relationship?
A. Establish boundaries and set goals
B. Perform an initial assessment
C. Summarize progress and conclude the relationship
D. Promote the client’s problem-solving skills
Behavioral Health Nursing (NUR2459 Final Exam) | Rasmussen
1. A patient with bipolar disorder has a lithium level of 2.1 mEq/L. Which clinical finding
should the nurse prioritize?
A. Fine hand tremors and mild nausea
B. Occasional muscle weakness
C. Polyuria and increased thirst
D. Ataxia and blurred vision
Answer: D
Rationale: A lithium level of 2.1 mEq/L indicates severe toxicity that requires immediate
intervention. Ataxia and blurred vision are signs of significant neurological impairment
that precede seizures and coma. The nurse must withhold the dose and notify the provider
to prevent further physiological deterioration.
2. A client with schizophrenia states, ‘The voices are telling me I am a bad person.’ Which
response by the nurse is most therapeutic?
A. ‘Let’s go to the dayroom and watch television together.’
B. ‘The voices are not real and you should ignore them.’
C. ‘Why do you think the voices are saying that?’
D. ‘I do not hear the voices, but I understand they are real to you.’
Answer: D
Rationale: Acknowledging the patient’s experience while presenting reality is a
fundamental technique in managing hallucinations. This approach validates the patient’s
feelings without reinforcing the false perception. It helps build trust and encourages the
patient to discuss their internal experiences safely.
3. A nurse is caring for a client who was just admitted with severe depression and suicidal
ideation. Which action is the priority?
A. Administering a prescribed antidepressant
B. Performing a search of the client’s belongings
C. Encouraging the client to attend group therapy
D. Assessing the client’s sleep patterns
Answer: B
,Rationale: Safety is the highest priority for a patient admitted with suicidal ideation.
Searching belongings ensures that the patient does not have access to harmful items such
as belts, shoelaces, or sharp objects. This immediate intervention provides a secure
environment while a more comprehensive treatment plan is developed.
4. A client is prescribed phenelzine (Nardil). Which food item should the nurse instruct the
client to avoid?
A. Fresh grilled chicken
B. Aged cheddar cheese
C. Steamed green beans
D. Baked white potato
Answer: B
Rationale: Phenelzine is an MAOI that requires a low-tyramine diet to prevent
hypertensive crisis. Aged cheeses are high in tyramine and can lead to a dangerous spike in
blood pressure. The nurse must educate the patient on identifying and avoiding fermented
or cured food products.
5. A patient exhibits muscle rigidity, a temperature of 103°F (39.4°C), and altered
consciousness while on haloperidol. What should the nurse do first?
A. Apply cooling blankets and stop the medication
B. Administer an extra dose of haloperidol
C. Encourage the patient to drink more fluids
D. Document the findings as a common side effect
Answer: A
Rationale: These symptoms are indicative of Neuroleptic Malignant Syndrome (NMS), a
life-threatening emergency. The nurse must immediately discontinue the antipsychotic
medication and initiate measures to lower the body temperature. Prompt medical
intervention and transfer to an intensive care setting are often necessary for stabilization.
6. Which assessment finding in a patient with anorexia nervosa is the most concerning?
A. Heart rate of 38 beats per minute
B. Amenorrhea for six months
C. Presence of lanugo on the back
D. Preoccupation with food recipes
Answer: A
, Rationale: A heart rate of 38 bpm indicates severe bradycardia, which can lead to cardiac
arrest and death in patients with eating disorders. While lanugo and amenorrhea are
common findings, they are not immediately life-threatening. The nurse must prioritize
cardiovascular stability and prepare for medical stabilization.
7. A client with Borderline Personality Disorder uses ‘splitting’ when talking to staff. How
should the nurse proceed?
A. Avoid talking to the client until they apologize
B. Hold a staff meeting to ensure a consistent approach
C. Agree with the client to prevent an outburst
D. Assign a different nurse to the client daily
Answer: B
Rationale: Splitting involves the patient seeing staff as either ‘all good’ or ‘all bad,’ which
often leads to conflict between team members. A consistent approach across the
multidisciplinary team prevents the patient from manipulating staff and maintains
professional boundaries. Open communication among staff is essential to counteract this
defense mechanism.
8. A nurse is assessing a client for alcohol withdrawal. Which symptom should be monitored
as an early sign?
A. Prolonged periods of sleep
B. Hypotension and bradycardia
C. Fine tremors and tachycardia
D. Increased appetite and lethargy
Answer: C
Rationale: Withdrawal symptoms typically begin 6 to 12 hours after the last drink, with
tremors and increased heart rate being primary early indicators. The nurse uses
assessment tools like the CIWA-Ar scale to quantify the severity of these symptoms.
Prompt recognition allows for timely administration of benzodiazepines to prevent
delirium tremens.
9. What is the primary goal of the ‘working phase’ in a therapeutic nurse-client relationship?
A. Establish boundaries and set goals
B. Perform an initial assessment
C. Summarize progress and conclude the relationship
D. Promote the client’s problem-solving skills
