NUR 2459 Exam 3 Actual Exam V3 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A patient with schizophrenia is admitted to the unit and reports hearing a voice saying,
‘The government is going to poison your food.’ Which nursing action is the priority?
A. Ask the patient, ‘What are you hearing right now?’
B. Allow the patient to eat only sealed, pre-packaged food items.
C. Explain that the food is safe and the kitchen staff are professional.
D. Administer a PRN dose of haloperidol immediately.
Answer: A
Rationale: The priority intervention for a patient experiencing hallucinations is to assess
the content of the hallucination to determine the risk of harm to self or others. Direct
questioning helps the nurse understand if the voices are ‘command hallucinations’ that
might lead to unsafe behavior. Once safety is assessed, the nurse can focus on reality
orientation and symptom management.
2. A client is diagnosed with Bipolar I Disorder and is currently in an acute manic phase.
Which meal choice is most appropriate for the nurse to provide?
A. Beef stew, mashed potatoes, and a cup of hot coffee.
B. A grilled cheese sandwich, an apple, and a carton of milk.
C. Spaghetti and meatballs with a side salad and water.
D. A bowl of vegetable soup and crackers.
Answer: B
Rationale: Patients in a manic state are hyperactive and often unable to sit down long
enough to eat a full meal. Providing ‘finger foods’ like a sandwich and fruit allows the
patient to maintain nutritional intake while on the move. High-calorie, high-protein
portable items are essential to prevent physical exhaustion and weight loss during mania.
3. A nurse is caring for a patient who has been taking Lithium Carbonate for two weeks. The
patient reports blurred vision, severe diarrhea, and tremors. Which action should the nurse
take first?
A. Reassure the patient that these are common side effects that will subside.
B. Notify the provider and prepare for a serum lithium level blood draw.
C. Administer the next scheduled dose of Lithium to maintain therapeutic levels.
D. Check the patient’s blood pressure and pulse rate.
,Answer: B
Rationale: Diarrhea, blurred vision, and tremors are early signs of lithium toxicity, which
can be life-threatening. The nurse must hold the medication and obtain a serum level to
assess for toxicity above the therapeutic range of 0.6-1.2 mEq/L. Prompt intervention is
necessary to prevent neurological damage or renal failure.
4. A patient is admitted for alcohol detoxification. Which assessment finding requires
immediate intervention by the nurse?
A. Patient states they have not had a drink in 12 hours.
B. Patient reports feeling anxious and irritable.
C. Tachycardia, diaphoresis, and hand tremors.
D. Coarse tremors and a heart rate of 90 bpm.
Answer: C
Rationale: Tachycardia and diaphoresis are physiological signs of autonomic hyperactivity
in alcohol withdrawal, which can progress to delirium tremens (DTs) or seizures. The
nurse must use a standardized assessment tool like the CIWA-Ar to determine the severity
of withdrawal. Immediate pharmacological intervention with benzodiazepines is often
required to ensure safety.
5. A client with Borderline Personality Disorder (BPD) tells a nurse, ‘You are the only nurse
who understands me; the others are mean and incompetent.’ What is this behavior known
as?
A. Splitting
B. Projection
C. Idealization
D. Reaction Formation
Answer: A
Rationale: Splitting is a common defense mechanism in BPD where individuals view
people or situations as either all good or all bad. This behavior often creates conflict among
the healthcare team as the patient tries to manipulate staff dynamics. The nursing team
must maintain consistent boundaries and communicate frequently to prevent this
manipulation.
6. A nurse is evaluating the effectiveness of Amitriptyline (a TCA) for a patient with
depression. Which finding would indicate a serious adverse effect?
A. Changes in cardiac rhythm on an ECG.
B. Urinary retention and constipation.
, C. Dry mouth and blurred vision.
D. Drowsiness in the late afternoon.
Answer: A
Rationale: Tricyclic antidepressants (TCAs) like Amitriptyline carry a high risk for
cardiotoxicity and dysrhythmias, especially in overdose. While anticholinergic effects like
dry mouth and constipation are common, cardiac changes are a priority safety concern.
Patients starting TCAs often require a baseline ECG and ongoing monitoring for prolonged
QT intervals.
7. A patient with Anorexia Nervosa is being admitted to an inpatient unit. Which assessment
finding should the nurse prioritize?
A. Potassium level of 2.8 mEq/L.
B. Presence of lanugo on the back and arms.
C. Body weight 25% below ideal body weight.
D. Amenorrhea for the past six months.
Answer: A
Rationale: Hypokalemia (low potassium) is a medical emergency that can lead to fatal
cardiac arrhythmias. While weight loss and lanugo are characteristic of anorexia,
electrolyte imbalances pose the most immediate threat to life. Stabilization of electrolytes
is the primary goal of acute medical intervention in eating disorders.
8. A patient is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result must the nurse monitor most closely?
A. Serum sodium levels
B. Absolute neutrophil count (ANC)
C. Blood urea nitrogen (BUN)
D. Aspartate aminotransferase (AST)
Answer: B
Rationale: Clozapine carries a black box warning for agranulocytosis, which is a severe
reduction in white blood cells that increases infection risk. Patients must have their ANC
monitored weekly for the first six months of treatment. The medication must be
discontinued if the ANC falls below a specific threshold to prevent life-threatening sepsis.
9. A nurse is assessing a client for potential suicidal ideation. Which statement by the client
requires the most immediate follow-up?
A. ‘I’ve been feeling really down and hopeless lately.’
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A patient with schizophrenia is admitted to the unit and reports hearing a voice saying,
‘The government is going to poison your food.’ Which nursing action is the priority?
A. Ask the patient, ‘What are you hearing right now?’
B. Allow the patient to eat only sealed, pre-packaged food items.
C. Explain that the food is safe and the kitchen staff are professional.
D. Administer a PRN dose of haloperidol immediately.
Answer: A
Rationale: The priority intervention for a patient experiencing hallucinations is to assess
the content of the hallucination to determine the risk of harm to self or others. Direct
questioning helps the nurse understand if the voices are ‘command hallucinations’ that
might lead to unsafe behavior. Once safety is assessed, the nurse can focus on reality
orientation and symptom management.
2. A client is diagnosed with Bipolar I Disorder and is currently in an acute manic phase.
Which meal choice is most appropriate for the nurse to provide?
A. Beef stew, mashed potatoes, and a cup of hot coffee.
B. A grilled cheese sandwich, an apple, and a carton of milk.
C. Spaghetti and meatballs with a side salad and water.
D. A bowl of vegetable soup and crackers.
Answer: B
Rationale: Patients in a manic state are hyperactive and often unable to sit down long
enough to eat a full meal. Providing ‘finger foods’ like a sandwich and fruit allows the
patient to maintain nutritional intake while on the move. High-calorie, high-protein
portable items are essential to prevent physical exhaustion and weight loss during mania.
3. A nurse is caring for a patient who has been taking Lithium Carbonate for two weeks. The
patient reports blurred vision, severe diarrhea, and tremors. Which action should the nurse
take first?
A. Reassure the patient that these are common side effects that will subside.
B. Notify the provider and prepare for a serum lithium level blood draw.
C. Administer the next scheduled dose of Lithium to maintain therapeutic levels.
D. Check the patient’s blood pressure and pulse rate.
,Answer: B
Rationale: Diarrhea, blurred vision, and tremors are early signs of lithium toxicity, which
can be life-threatening. The nurse must hold the medication and obtain a serum level to
assess for toxicity above the therapeutic range of 0.6-1.2 mEq/L. Prompt intervention is
necessary to prevent neurological damage or renal failure.
4. A patient is admitted for alcohol detoxification. Which assessment finding requires
immediate intervention by the nurse?
A. Patient states they have not had a drink in 12 hours.
B. Patient reports feeling anxious and irritable.
C. Tachycardia, diaphoresis, and hand tremors.
D. Coarse tremors and a heart rate of 90 bpm.
Answer: C
Rationale: Tachycardia and diaphoresis are physiological signs of autonomic hyperactivity
in alcohol withdrawal, which can progress to delirium tremens (DTs) or seizures. The
nurse must use a standardized assessment tool like the CIWA-Ar to determine the severity
of withdrawal. Immediate pharmacological intervention with benzodiazepines is often
required to ensure safety.
5. A client with Borderline Personality Disorder (BPD) tells a nurse, ‘You are the only nurse
who understands me; the others are mean and incompetent.’ What is this behavior known
as?
A. Splitting
B. Projection
C. Idealization
D. Reaction Formation
Answer: A
Rationale: Splitting is a common defense mechanism in BPD where individuals view
people or situations as either all good or all bad. This behavior often creates conflict among
the healthcare team as the patient tries to manipulate staff dynamics. The nursing team
must maintain consistent boundaries and communicate frequently to prevent this
manipulation.
6. A nurse is evaluating the effectiveness of Amitriptyline (a TCA) for a patient with
depression. Which finding would indicate a serious adverse effect?
A. Changes in cardiac rhythm on an ECG.
B. Urinary retention and constipation.
, C. Dry mouth and blurred vision.
D. Drowsiness in the late afternoon.
Answer: A
Rationale: Tricyclic antidepressants (TCAs) like Amitriptyline carry a high risk for
cardiotoxicity and dysrhythmias, especially in overdose. While anticholinergic effects like
dry mouth and constipation are common, cardiac changes are a priority safety concern.
Patients starting TCAs often require a baseline ECG and ongoing monitoring for prolonged
QT intervals.
7. A patient with Anorexia Nervosa is being admitted to an inpatient unit. Which assessment
finding should the nurse prioritize?
A. Potassium level of 2.8 mEq/L.
B. Presence of lanugo on the back and arms.
C. Body weight 25% below ideal body weight.
D. Amenorrhea for the past six months.
Answer: A
Rationale: Hypokalemia (low potassium) is a medical emergency that can lead to fatal
cardiac arrhythmias. While weight loss and lanugo are characteristic of anorexia,
electrolyte imbalances pose the most immediate threat to life. Stabilization of electrolytes
is the primary goal of acute medical intervention in eating disorders.
8. A patient is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result must the nurse monitor most closely?
A. Serum sodium levels
B. Absolute neutrophil count (ANC)
C. Blood urea nitrogen (BUN)
D. Aspartate aminotransferase (AST)
Answer: B
Rationale: Clozapine carries a black box warning for agranulocytosis, which is a severe
reduction in white blood cells that increases infection risk. Patients must have their ANC
monitored weekly for the first six months of treatment. The medication must be
discontinued if the ANC falls below a specific threshold to prevent life-threatening sepsis.
9. A nurse is assessing a client for potential suicidal ideation. Which statement by the client
requires the most immediate follow-up?
A. ‘I’ve been feeling really down and hopeless lately.’
