NUR 2459 Exam 2 Actual Exam V3 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client diagnosed with Bipolar I Disorder is currently experiencing an acute manic episode
and is hyperactive, pacing the hallways, and refusing to sit for meals. Which nursing
intervention is most appropriate to maintain the client’s nutrition?
A. Offer the client a large bowl of soup to ensure hydration and caloric intake.
B. Escort the client to a quiet room and insist they finish a full meal.
C. Provide high-calorie, high-protein finger foods that can be eaten while walking.
D. Wait until the client is exhausted to offer a heavy meal in bed.
Answer: C
Rationale: During an acute manic episode, patients often lack the focus to sit through a
traditional meal due to psychomotor agitation. Providing finger foods allows the patient to
consume necessary calories while remaining mobile. This intervention prioritizes
nutritional intake without escalating the patient’s agitation through forced restriction.
2. A nurse is assessing a client for potential suicide risk. Which of the following statements by
the client would be of the highest priority for the nurse to follow up on immediately?
A. I have been feeling really down and tired lately.
B. I finally found a way to end all my pain this weekend.
C. I wish I didn’t have to wake up tomorrow morning.
D. My family would be better off if I wasn’t around anymore.
Answer: B
Rationale: This statement indicates a specific plan and intent to act, which represents the
highest level of lethality and immediate risk. While other statements show suicidal ideation
or hopelessness, the mention of a specific timeframe and method requires urgent
intervention. The nurse must prioritize patient safety by initiating suicide precautions and
further assessing the plan’s details.
3. A client with schizophrenia is standing in the corner of the dayroom and appears to be
talking to someone who is not there. What is the most therapeutic response by the nurse?
A. Who are you talking to? There is nobody else in this corner.
B. What are the voices telling you to do right now?
C. You should stop talking to the air because it makes other patients nervous.
D. I understand that you are hearing voices, but I do not hear them.
,Answer: D
Rationale: This response acknowledges the patient’s subjective experience without
validating the hallucination as reality. It provides a reality check in a non-confrontational
manner, which is a core principle in communicating with psychotic patients. By stating that
the nurse does not hear the voices, a boundary between the patient’s internal experience
and objective reality is established.
4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following symptoms should the nurse instruct the client to report as an early sign of toxicity?
A. Increased appetite and weight gain.
B. Fine hand tremors and mild thirst.
C. Occasional dry mouth and metallic taste.
D. Persistent diarrhea, vomiting, and muscle weakness.
Answer: D
Rationale: Gastrointestinal distress such as diarrhea and vomiting, along with muscle
weakness, are classic early indicators of lithium toxicity. Fine tremors and mild thirst are
common side effects that usually do not indicate toxicity. Educating the patient on these
signs is critical because the therapeutic index for lithium is very narrow, necessitating close
monitoring.
5. A client is experiencing a severe panic attack in the outpatient clinic. What is the nurse’s
priority action?
A. Teach the client deep breathing exercises to use during the attack.
B. Leave the client alone to allow them space to calm down.
C. Stay with the client and use short, simple sentences.
D. Ask the client to explain what triggered their anxiety today.
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 safety and a sense of
security, which is the immediate priority. Using short, simple sentences ensures the patient
can understand the nurse’s presence and instructions despite their cognitive narrowing.
6. A nurse is caring for a client who was started on Sertraline (an SSRI) two weeks ago. The
client states, ‘I don’t think this medicine is working; I still feel sad.’ What is the best response
by the nurse?
A. It usually takes 2 to 4 weeks for the full antidepressant effect to occur.
B. We should probably ask the doctor to increase your dose today.
, C. You might need to switch to a different class of medication.
D. It is important that you try to think more positively while taking the drug.
Answer: A
Rationale: SSRIs typically have a delayed onset of action, often taking several weeks to
show significant improvement in mood. Patients need to be educated on this timeline to
ensure adherence and prevent premature discontinuation. Providing this information
manages the patient’s expectations and encourages them to continue the treatment plan as
prescribed.
7. A nurse is using therapeutic communication with a client who is distressed. The client says,
‘Everything in my life is a mess. I lost my job, and now my spouse wants a divorce.’ The nurse
responds, ‘You feel like your life is falling apart because of these changes.’ Which technique is
the nurse using?
A. Restating
B. Reflecting
C. Focusing
D. Summarizing
Answer: B
Rationale: Reflecting involves directing the patient’s feelings back to them, which helps the
patient recognize and accept their own emotions. In this scenario, the nurse is mirroring
the patient’s underlying emotional state rather than just repeating words. This technique
validates the patient’s experience and encourages deeper exploration of their feelings.
8. A client with schizophrenia tells the nurse, ‘The FBI has planted a microphone in my tooth
to listen to my thoughts.’ How should the nurse document this finding?
A. Paranoid delusion
B. Delusion of grandeur
C. Hallucination
D. Ideas of reference
Answer: A
Rationale: A paranoid delusion is a fixed, false belief where the individual believes they are
being persecuted or conspired against by others. The belief that the FBI is monitoring
thoughts via a dental implant is a classic example of this symptom. Accurate documentation
is essential for tracking the severity of the patient’s psychosis and their response to
treatment.
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client diagnosed with Bipolar I Disorder is currently experiencing an acute manic episode
and is hyperactive, pacing the hallways, and refusing to sit for meals. Which nursing
intervention is most appropriate to maintain the client’s nutrition?
A. Offer the client a large bowl of soup to ensure hydration and caloric intake.
B. Escort the client to a quiet room and insist they finish a full meal.
C. Provide high-calorie, high-protein finger foods that can be eaten while walking.
D. Wait until the client is exhausted to offer a heavy meal in bed.
Answer: C
Rationale: During an acute manic episode, patients often lack the focus to sit through a
traditional meal due to psychomotor agitation. Providing finger foods allows the patient to
consume necessary calories while remaining mobile. This intervention prioritizes
nutritional intake without escalating the patient’s agitation through forced restriction.
2. A nurse is assessing a client for potential suicide risk. Which of the following statements by
the client would be of the highest priority for the nurse to follow up on immediately?
A. I have been feeling really down and tired lately.
B. I finally found a way to end all my pain this weekend.
C. I wish I didn’t have to wake up tomorrow morning.
D. My family would be better off if I wasn’t around anymore.
Answer: B
Rationale: This statement indicates a specific plan and intent to act, which represents the
highest level of lethality and immediate risk. While other statements show suicidal ideation
or hopelessness, the mention of a specific timeframe and method requires urgent
intervention. The nurse must prioritize patient safety by initiating suicide precautions and
further assessing the plan’s details.
3. A client with schizophrenia is standing in the corner of the dayroom and appears to be
talking to someone who is not there. What is the most therapeutic response by the nurse?
A. Who are you talking to? There is nobody else in this corner.
B. What are the voices telling you to do right now?
C. You should stop talking to the air because it makes other patients nervous.
D. I understand that you are hearing voices, but I do not hear them.
,Answer: D
Rationale: This response acknowledges the patient’s subjective experience without
validating the hallucination as reality. It provides a reality check in a non-confrontational
manner, which is a core principle in communicating with psychotic patients. By stating that
the nurse does not hear the voices, a boundary between the patient’s internal experience
and objective reality is established.
4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which of the
following symptoms should the nurse instruct the client to report as an early sign of toxicity?
A. Increased appetite and weight gain.
B. Fine hand tremors and mild thirst.
C. Occasional dry mouth and metallic taste.
D. Persistent diarrhea, vomiting, and muscle weakness.
Answer: D
Rationale: Gastrointestinal distress such as diarrhea and vomiting, along with muscle
weakness, are classic early indicators of lithium toxicity. Fine tremors and mild thirst are
common side effects that usually do not indicate toxicity. Educating the patient on these
signs is critical because the therapeutic index for lithium is very narrow, necessitating close
monitoring.
5. A client is experiencing a severe panic attack in the outpatient clinic. What is the nurse’s
priority action?
A. Teach the client deep breathing exercises to use during the attack.
B. Leave the client alone to allow them space to calm down.
C. Stay with the client and use short, simple sentences.
D. Ask the client to explain what triggered their anxiety today.
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 safety and a sense of
security, which is the immediate priority. Using short, simple sentences ensures the patient
can understand the nurse’s presence and instructions despite their cognitive narrowing.
6. A nurse is caring for a client who was started on Sertraline (an SSRI) two weeks ago. The
client states, ‘I don’t think this medicine is working; I still feel sad.’ What is the best response
by the nurse?
A. It usually takes 2 to 4 weeks for the full antidepressant effect to occur.
B. We should probably ask the doctor to increase your dose today.
, C. You might need to switch to a different class of medication.
D. It is important that you try to think more positively while taking the drug.
Answer: A
Rationale: SSRIs typically have a delayed onset of action, often taking several weeks to
show significant improvement in mood. Patients need to be educated on this timeline to
ensure adherence and prevent premature discontinuation. Providing this information
manages the patient’s expectations and encourages them to continue the treatment plan as
prescribed.
7. A nurse is using therapeutic communication with a client who is distressed. The client says,
‘Everything in my life is a mess. I lost my job, and now my spouse wants a divorce.’ The nurse
responds, ‘You feel like your life is falling apart because of these changes.’ Which technique is
the nurse using?
A. Restating
B. Reflecting
C. Focusing
D. Summarizing
Answer: B
Rationale: Reflecting involves directing the patient’s feelings back to them, which helps the
patient recognize and accept their own emotions. In this scenario, the nurse is mirroring
the patient’s underlying emotional state rather than just repeating words. This technique
validates the patient’s experience and encourages deeper exploration of their feelings.
8. A client with schizophrenia tells the nurse, ‘The FBI has planted a microphone in my tooth
to listen to my thoughts.’ How should the nurse document this finding?
A. Paranoid delusion
B. Delusion of grandeur
C. Hallucination
D. Ideas of reference
Answer: A
Rationale: A paranoid delusion is a fixed, false belief where the individual believes they are
being persecuted or conspired against by others. The belief that the FBI is monitoring
thoughts via a dental implant is a classic example of this symptom. Accurate documentation
is essential for tracking the severity of the patient’s psychosis and their response to
treatment.
