NUR 2459 Exam 3 Actual Exam V1 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A patient is admitted to the emergency department experiencing a severe panic attack.
Which nursing intervention is the highest priority?
A. Teach the patient deep breathing exercises immediately.
B. Ask the patient to explain what triggered the attack.
C. Stay with the patient and provide a calm, quiet environment.
D. Administer a high dose of an oral antidepressant.
Answer: C
Rationale: During a severe panic attack, the patient is unable to process complex
information or learn new skills. Staying with the patient provides a sense of safety and
security, which is the immediate priority to prevent injury. A quiet environment helps
reduce the external stimuli that contribute to the overwhelming anxiety response.
2. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily arranging
objects on a bedside table. How should the nurse initially manage this behavior?
A. Physically remove the objects to prevent the ritual.
B. Tell the client that the behavior is irrational and must stop.
C. Administer a PRN sedative when the ritual begins.
D. Allow the client extra time to complete the rituals initially.
Answer: D
Rationale: Initially, the nurse should allow the client to perform the rituals to avoid a
sudden increase in anxiety levels that could lead to panic. Attempting to stop rituals
abruptly before the client has developed alternative coping mechanisms is
counterproductive. As treatment progresses, the nurse and client will work together to set
limits on the behavior.
3. A nurse is caring for a client with Anorexia Nervosa who is starting a refeeding protocol.
Which laboratory value should the nurse monitor most closely to detect refeeding syndrome?
A. Serum Phosphate
B. Serum Potassium
C. Blood Urea Nitrogen
D. Hemoglobin A1c
,Answer: A
Rationale: Refeeding syndrome is a potentially fatal complication characterized by severe
electrolyte shifts when a malnourished patient begins to eat. Hypophosphatemia is the
hallmark sign because the body uses up remaining phosphorus for ATP production as it
shifts from a catabolic to an anabolic state. Nurses must monitor phosphate, potassium, and
magnesium levels to ensure the patient’s physiological safety during nutritional
rehabilitation.
4. A client with Borderline Personality Disorder (BPD) tells a night shift nurse, ‘The day shift
nurse is terrible, but you are the only one who truly understands me.’ This is an example of:
A. Rationalization
B. Intellectualization
C. Reaction Formation
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the individual
perceives others as either ‘all good’ or ‘all bad.’ This behavior often leads to conflict within
the nursing staff as the patient attempts to manipulate interpersonal relationships.
Consistent communication among the treatment team is essential to prevent the negative
effects of splitting and maintain a therapeutic milieu.
5. A client is admitted for alcohol detoxification. Which assessment finding is most indicative
of the onset of Delirium Tremens (DTs)?
A. Mild tremors and headache
B. Hallucinations, tachycardia, and hypertension
C. Increased appetite and lethargy
D. Bradypnea and pinpoint pupils
Answer: B
Rationale: Delirium Tremens is the most severe form of alcohol withdrawal and is
considered a medical emergency. It is characterized by autonomic hyperactivity, including
tachycardia, diaphoresis, hypertension, and sensory disturbances like hallucinations. Early
recognition and treatment with benzodiazepines are critical to prevent seizures and death.
6. A nurse is providing education to a client prescribed Disulfiram (Antabuse) for alcohol use
disorder. Which statement by the client indicates a need for further teaching?
A. ‘I should avoid using alcohol-based mouthwashes.’
B. ‘I must check labels on cough syrups and vanilla extracts.’
, C. ‘I can have a glass of wine with dinner once I have been on the medication for a week.’
D. ‘I should wait at least 14 days after stopping the drug before consuming any alcohol.’
Answer: C
Rationale: Disulfiram works by causing a severe adverse reaction if any alcohol is ingested,
including flushing, nausea, and vomiting. Clients must be strictly educated to avoid all
forms of alcohol, including hidden sources in foods and hygiene products. The client’s
statement about having wine indicates a dangerous lack of understanding regarding the
drug’s mechanism and risks.
7. A client with Somatic Symptom Disorder frequently complains of localized pain for which
no medical cause can be found. What is the most appropriate nursing goal?
A. The client will admit that the pain is purely psychological.
B. The client will verbalize a decrease in pain intensity.
C. The client will stop seeking medical attention for physical symptoms.
D. The client will develop more adaptive coping mechanisms to deal with stress.
Answer: D
Rationale: In Somatic Symptom Disorder, the physical symptoms are a manifestation of
psychological distress. The nurse’s goal is not to disprove the pain, which is real to the
client, but to help the client manage the underlying stress. Developing adaptive coping
skills allows the client to address the root cause of the anxiety rather than focusing on
physical symptoms.
8. A client is diagnosed with Conversion Disorder (Functional Neurological Symptom Disorder)
after suddenly becoming blind. The nurse notes the client seems unconcerned about the
blindness. This is known as:
A. Anosognosia
B. La belle indifference
C. Malingering
D. Secondary gain
Answer: B
Rationale: ‘La belle indifference’ refers to a paradoxical lack of concern about a severe
physical symptom, which is a classic feature of Conversion Disorder. This lack of anxiety
suggests that the physical symptom is serving a psychological purpose, such as reducing
internal conflict. This phenomenon helps distinguish the disorder from other conditions
where the patient would be highly distressed by the loss of function.
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A patient is admitted to the emergency department experiencing a severe panic attack.
Which nursing intervention is the highest priority?
A. Teach the patient deep breathing exercises immediately.
B. Ask the patient to explain what triggered the attack.
C. Stay with the patient and provide a calm, quiet environment.
D. Administer a high dose of an oral antidepressant.
Answer: C
Rationale: During a severe panic attack, the patient is unable to process complex
information or learn new skills. Staying with the patient provides a sense of safety and
security, which is the immediate priority to prevent injury. A quiet environment helps
reduce the external stimuli that contribute to the overwhelming anxiety response.
2. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily arranging
objects on a bedside table. How should the nurse initially manage this behavior?
A. Physically remove the objects to prevent the ritual.
B. Tell the client that the behavior is irrational and must stop.
C. Administer a PRN sedative when the ritual begins.
D. Allow the client extra time to complete the rituals initially.
Answer: D
Rationale: Initially, the nurse should allow the client to perform the rituals to avoid a
sudden increase in anxiety levels that could lead to panic. Attempting to stop rituals
abruptly before the client has developed alternative coping mechanisms is
counterproductive. As treatment progresses, the nurse and client will work together to set
limits on the behavior.
3. A nurse is caring for a client with Anorexia Nervosa who is starting a refeeding protocol.
Which laboratory value should the nurse monitor most closely to detect refeeding syndrome?
A. Serum Phosphate
B. Serum Potassium
C. Blood Urea Nitrogen
D. Hemoglobin A1c
,Answer: A
Rationale: Refeeding syndrome is a potentially fatal complication characterized by severe
electrolyte shifts when a malnourished patient begins to eat. Hypophosphatemia is the
hallmark sign because the body uses up remaining phosphorus for ATP production as it
shifts from a catabolic to an anabolic state. Nurses must monitor phosphate, potassium, and
magnesium levels to ensure the patient’s physiological safety during nutritional
rehabilitation.
4. A client with Borderline Personality Disorder (BPD) tells a night shift nurse, ‘The day shift
nurse is terrible, but you are the only one who truly understands me.’ This is an example of:
A. Rationalization
B. Intellectualization
C. Reaction Formation
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the individual
perceives others as either ‘all good’ or ‘all bad.’ This behavior often leads to conflict within
the nursing staff as the patient attempts to manipulate interpersonal relationships.
Consistent communication among the treatment team is essential to prevent the negative
effects of splitting and maintain a therapeutic milieu.
5. A client is admitted for alcohol detoxification. Which assessment finding is most indicative
of the onset of Delirium Tremens (DTs)?
A. Mild tremors and headache
B. Hallucinations, tachycardia, and hypertension
C. Increased appetite and lethargy
D. Bradypnea and pinpoint pupils
Answer: B
Rationale: Delirium Tremens is the most severe form of alcohol withdrawal and is
considered a medical emergency. It is characterized by autonomic hyperactivity, including
tachycardia, diaphoresis, hypertension, and sensory disturbances like hallucinations. Early
recognition and treatment with benzodiazepines are critical to prevent seizures and death.
6. A nurse is providing education to a client prescribed Disulfiram (Antabuse) for alcohol use
disorder. Which statement by the client indicates a need for further teaching?
A. ‘I should avoid using alcohol-based mouthwashes.’
B. ‘I must check labels on cough syrups and vanilla extracts.’
, C. ‘I can have a glass of wine with dinner once I have been on the medication for a week.’
D. ‘I should wait at least 14 days after stopping the drug before consuming any alcohol.’
Answer: C
Rationale: Disulfiram works by causing a severe adverse reaction if any alcohol is ingested,
including flushing, nausea, and vomiting. Clients must be strictly educated to avoid all
forms of alcohol, including hidden sources in foods and hygiene products. The client’s
statement about having wine indicates a dangerous lack of understanding regarding the
drug’s mechanism and risks.
7. A client with Somatic Symptom Disorder frequently complains of localized pain for which
no medical cause can be found. What is the most appropriate nursing goal?
A. The client will admit that the pain is purely psychological.
B. The client will verbalize a decrease in pain intensity.
C. The client will stop seeking medical attention for physical symptoms.
D. The client will develop more adaptive coping mechanisms to deal with stress.
Answer: D
Rationale: In Somatic Symptom Disorder, the physical symptoms are a manifestation of
psychological distress. The nurse’s goal is not to disprove the pain, which is real to the
client, but to help the client manage the underlying stress. Developing adaptive coping
skills allows the client to address the root cause of the anxiety rather than focusing on
physical symptoms.
8. A client is diagnosed with Conversion Disorder (Functional Neurological Symptom Disorder)
after suddenly becoming blind. The nurse notes the client seems unconcerned about the
blindness. This is known as:
A. Anosognosia
B. La belle indifference
C. Malingering
D. Secondary gain
Answer: B
Rationale: ‘La belle indifference’ refers to a paradoxical lack of concern about a severe
physical symptom, which is a classic feature of Conversion Disorder. This lack of anxiety
suggests that the physical symptom is serving a psychological purpose, such as reducing
internal conflict. This phenomenon helps distinguish the disorder from other conditions
where the patient would be highly distressed by the loss of function.
