NUR 2459 Exam 3 Actual Exam V1 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A client with major depressive disorder who has been withdrawn and suicidal suddenly
appears energetic and cheerful. What should the nurse prioritize in the assessment?
A. Check the client’s chart for a discharge order.
B. Commend the client for their positive progress.
C. Request a decrease in the level of observation.
D. Assess the client’s current suicide plan and intent.
Answer: D
Rationale: A sudden improvement in mood in a severely depressed client often indicates
that the client has made a decision to complete suicide. The relief of having a plan can
result in an increased energy level and a brighter affect. The nurse must prioritize a direct
assessment of suicide lethality to ensure the client’s safety.
2. A client diagnosed with Bipolar I Disorder is in a manic phase, pacing the hallways and
refusing to sit for meals. Which nursing intervention is most appropriate?
A. Insist that the client sit in the dining room for 20 minutes.
B. Place the client in a quiet room with a locked door.
C. Encourage the client to join a competitive group volleyball game.
D. Provide high-calorie finger foods that the client can eat while moving.
Answer: D
Rationale: During an acute manic episode, patients are often too hyperactive to sit down
for a full meal, leading to a risk of nutritional deficit and dehydration. High-calorie finger
foods allow the patient to maintain nutritional intake while remaining mobile. This
intervention prioritizes physical health and meets the patient’s immediate physiological
needs.
3. A nurse is caring for a client who is experiencing auditory hallucinations telling them to
‘hurt others.’ Which action is the priority for the nurse?
A. Tell the client that the voices are not real and to ignore them.
B. Ask the client what the voices are saying to determine the risk.
C. Leave the client alone to reduce environmental stimulation.
D. Administer an extra dose of an anti-anxiety medication immediately.
,Answer: B
Rationale: Assessment of command hallucinations is the highest priority to ensure the
safety of the client and others on the unit. The nurse must determine exactly what the
voices are commanding the client to do to implement appropriate safety precautions.
Validating the experience while focusing on safety is a core principle of psychiatric nursing
management.
4. A client is prescribed Lithium Carbonate for the management of Bipolar Disorder. The nurse
recognizes which symptom as an early sign of lithium toxicity?
A. Increased energy and rapid speech.
B. Nausea, vomiting, and fine hand tremors.
C. Seizures and cardiovascular collapse.
D. A white blood cell count of 15,000/mm3.
Answer: B
Rationale: Early signs of lithium toxicity generally appear at blood levels between 1.5 and
2.0 mEq/L and include gastrointestinal distress and fine tremors. The nurse must monitor
these symptoms closely and check serum lithium levels to prevent progression to severe
toxicity. Patient education regarding these early warning signs is vital for medication
compliance and safety.
5. A client with Borderline Personality Disorder (BPD) tells the night nurse, ‘You are the only
one who cares about me; the day nurse is so mean.’ This is an example of:
A. Rationalization
B. Displacement
C. Sublimation
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 can create conflict among the
nursing staff and disrupt the therapeutic milieu. The nursing team should respond with a
consistent, united approach to maintain boundaries and minimize the impact of splitting.
6. A nurse is assessing a client for alcohol withdrawal. Which of the following findings would
indicate the need for immediate medical intervention?
A. Tachycardia, diaphoresis, and elevated blood pressure
B. Mild tremors and headache
C. Increased appetite and lethargy
, D. Complaints of feeling sad and lonely
Answer: A
Rationale: Autonomic hyperactivity, such as tachycardia and hypertension, are signs of
significant alcohol withdrawal that can progress to delirium tremens. The nurse must
prioritize the administration of benzodiazepines and frequent monitoring of vital signs.
Failure to treat these symptoms can lead to seizures or cardiac events.
7. The nurse is caring for a client with Schizophrenia who is experiencing negative symptoms.
Which finding is consistent with this classification?
A. Flat affect and social withdrawal
B. Hallucinations and delusions
C. Disorganized speech and behavior
D. Agitation and pressured speech
Answer: A
Rationale: Negative symptoms of schizophrenia involve a loss or diminution of normal
functions, such as affect, motivation, and social interaction. These symptoms are often
more difficult to treat than positive symptoms and significantly impact the client’s ability to
function. Identifying these symptoms helps the nurse develop a care plan focused on social
skills and daily living activities.
8. A client is admitted involuntarily to a psychiatric unit. Which right does the client still
retain?
A. The right to leave the hospital at any time.
B. The right to carry weapons for self-defense.
C. The right to refuse treatment and medications.
D. The right to choose their own roommate.
Answer: C
Rationale: Involuntary admission does not automatically strip a client of their right to
refuse psychotropic medications, unless a court has deemed them incompetent. The nurse
must respect the client’s autonomy while ensuring safety through alternative interventions.
Ethical nursing practice requires balancing the client’s rights with the need for safety.
9. A nurse is initiating a therapeutic relationship with a client. Which action is most important
during the orientation phase?
A. Begin teaching the client new coping mechanisms.
B. Explore the client’s past trauma in detail.
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A client with major depressive disorder who has been withdrawn and suicidal suddenly
appears energetic and cheerful. What should the nurse prioritize in the assessment?
A. Check the client’s chart for a discharge order.
B. Commend the client for their positive progress.
C. Request a decrease in the level of observation.
D. Assess the client’s current suicide plan and intent.
Answer: D
Rationale: A sudden improvement in mood in a severely depressed client often indicates
that the client has made a decision to complete suicide. The relief of having a plan can
result in an increased energy level and a brighter affect. The nurse must prioritize a direct
assessment of suicide lethality to ensure the client’s safety.
2. A client diagnosed with Bipolar I Disorder is in a manic phase, pacing the hallways and
refusing to sit for meals. Which nursing intervention is most appropriate?
A. Insist that the client sit in the dining room for 20 minutes.
B. Place the client in a quiet room with a locked door.
C. Encourage the client to join a competitive group volleyball game.
D. Provide high-calorie finger foods that the client can eat while moving.
Answer: D
Rationale: During an acute manic episode, patients are often too hyperactive to sit down
for a full meal, leading to a risk of nutritional deficit and dehydration. High-calorie finger
foods allow the patient to maintain nutritional intake while remaining mobile. This
intervention prioritizes physical health and meets the patient’s immediate physiological
needs.
3. A nurse is caring for a client who is experiencing auditory hallucinations telling them to
‘hurt others.’ Which action is the priority for the nurse?
A. Tell the client that the voices are not real and to ignore them.
B. Ask the client what the voices are saying to determine the risk.
C. Leave the client alone to reduce environmental stimulation.
D. Administer an extra dose of an anti-anxiety medication immediately.
,Answer: B
Rationale: Assessment of command hallucinations is the highest priority to ensure the
safety of the client and others on the unit. The nurse must determine exactly what the
voices are commanding the client to do to implement appropriate safety precautions.
Validating the experience while focusing on safety is a core principle of psychiatric nursing
management.
4. A client is prescribed Lithium Carbonate for the management of Bipolar Disorder. The nurse
recognizes which symptom as an early sign of lithium toxicity?
A. Increased energy and rapid speech.
B. Nausea, vomiting, and fine hand tremors.
C. Seizures and cardiovascular collapse.
D. A white blood cell count of 15,000/mm3.
Answer: B
Rationale: Early signs of lithium toxicity generally appear at blood levels between 1.5 and
2.0 mEq/L and include gastrointestinal distress and fine tremors. The nurse must monitor
these symptoms closely and check serum lithium levels to prevent progression to severe
toxicity. Patient education regarding these early warning signs is vital for medication
compliance and safety.
5. A client with Borderline Personality Disorder (BPD) tells the night nurse, ‘You are the only
one who cares about me; the day nurse is so mean.’ This is an example of:
A. Rationalization
B. Displacement
C. Sublimation
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 can create conflict among the
nursing staff and disrupt the therapeutic milieu. The nursing team should respond with a
consistent, united approach to maintain boundaries and minimize the impact of splitting.
6. A nurse is assessing a client for alcohol withdrawal. Which of the following findings would
indicate the need for immediate medical intervention?
A. Tachycardia, diaphoresis, and elevated blood pressure
B. Mild tremors and headache
C. Increased appetite and lethargy
, D. Complaints of feeling sad and lonely
Answer: A
Rationale: Autonomic hyperactivity, such as tachycardia and hypertension, are signs of
significant alcohol withdrawal that can progress to delirium tremens. The nurse must
prioritize the administration of benzodiazepines and frequent monitoring of vital signs.
Failure to treat these symptoms can lead to seizures or cardiac events.
7. The nurse is caring for a client with Schizophrenia who is experiencing negative symptoms.
Which finding is consistent with this classification?
A. Flat affect and social withdrawal
B. Hallucinations and delusions
C. Disorganized speech and behavior
D. Agitation and pressured speech
Answer: A
Rationale: Negative symptoms of schizophrenia involve a loss or diminution of normal
functions, such as affect, motivation, and social interaction. These symptoms are often
more difficult to treat than positive symptoms and significantly impact the client’s ability to
function. Identifying these symptoms helps the nurse develop a care plan focused on social
skills and daily living activities.
8. A client is admitted involuntarily to a psychiatric unit. Which right does the client still
retain?
A. The right to leave the hospital at any time.
B. The right to carry weapons for self-defense.
C. The right to refuse treatment and medications.
D. The right to choose their own roommate.
Answer: C
Rationale: Involuntary admission does not automatically strip a client of their right to
refuse psychotropic medications, unless a court has deemed them incompetent. The nurse
must respect the client’s autonomy while ensuring safety through alternative interventions.
Ethical nursing practice requires balancing the client’s rights with the need for safety.
9. A nurse is initiating a therapeutic relationship with a client. Which action is most important
during the orientation phase?
A. Begin teaching the client new coping mechanisms.
B. Explore the client’s past trauma in detail.
