NUR 2459 Exam 3 Actual Exam V2 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of schizophrenia and is hearing
voices telling them to ‘hurt the others.’ Which is the priority nursing intervention?
A. Tell the client that the voices are not real and to ignore them.
B. Place the client in a seclusion room immediately for safety.
C. Ask the client what the voices are saying to assess for command hallucinations.
D. Administer a PRN dose of an anti-anxiety medication.
Answer: C
Rationale: Safety is the absolute priority when dealing with hallucinations that involve
potential harm. Identifying the specific content of command hallucinations allows the nurse
to implement appropriate safety precautions for the client and others. This assessment is
the first step in the nursing process before intervention or medication administration.
2. A nurse is caring for a client with Bipolar I Disorder who is experiencing an acute manic
episode. The client is pacing the hallway and refusing to sit for meals. Which nutritional
intervention is most appropriate?
A. Allow the client to eat in their room alone to reduce stimuli.
B. Provide high-calorie, high-protein finger foods that can be eaten while walking.
C. Place the client on a liquid diet to ensure hydration.
D. Wait until the manic episode subsides to offer nutrition.
Answer: B
Rationale: Clients in an acute manic state often have excessive physical activity and cannot
sit long enough to eat a full meal. Providing finger foods allows them to maintain necessary
caloric intake and hydration while remaining mobile. This intervention addresses the
physical need for energy without forcing the client into a restrictive environment that
might escalate agitation.
3. A client has been taking Lithium for two weeks to manage Bipolar Disorder. The client
reports blurred vision, severe diarrhea, and tremors. What is the nurse’s priority action?
A. Advise the client to increase their salt intake immediately.
B. Administer an antidiarrheal medication and reassess in four hours.
C. Document the findings as common side effects of early lithium therapy.
D. Instruct the client to withhold the next dose and prepare for a serum lithium level check.
,Answer: D
Rationale: The symptoms described are classic indicators of lithium toxicity, which can be
life-threatening if not addressed. Lithium has a narrow therapeutic index, so any signs of
toxicity require immediate cessation of the drug and laboratory verification. Prompt
intervention is necessary to prevent severe neurological damage or renal failure.
4. A nurse is performing a suicide risk assessment on a newly admitted client. The client
states, ‘I won’t be a problem for anyone much longer.’ How should the nurse respond?
A. Why do you feel like you are a problem?
B. Are you thinking of hurting or killing yourself?
C. You have so much to live for, things will get better.
D. I will make sure someone stays with you all the time.
Answer: B
Rationale: When a client makes a veiled suicide threat, the nurse must use direct and clear
language to assess for intent and plan. Vague responses or false reassurances are non-
therapeutic and may miss a critical window for intervention. Directly asking about suicidal
ideation is a standard safety protocol in mental health nursing.
5. A client diagnosed with Borderline Personality Disorder is angry at the primary nurse and
tells another nurse, ‘You are the only one who cares; my other nurse is incompetent.’ This
behavior is an example of:
A. Rationalization
B. Splitting
C. Reaction Formation
D. Displacement
Answer: B
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the individual views people as all good or all bad. This behavior often creates
conflict within the treatment team and is a way for the client to manage internal anxiety.
The nursing staff must maintain consistent boundaries and communicate frequently to
avoid being manipulated by this behavior.
6. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result must the nurse monitor most closely?
A. Serum Potassium
B. Blood Urea Nitrogen (BUN)
C. White Blood Cell (WBC) count
, D. Hemoglobin A1c
Answer: C
Rationale: Clozapine carries a high risk of agranulocytosis, which is a severe and
potentially fatal drop in white blood cell counts. Regular monitoring of the WBC and
Absolute Neutrophil Count (ANC) is a legal and safety requirement for clients on this
medication. Nurses must educate clients to report any signs of infection, such as fever or
sore throat, immediately.
7. During an admission assessment, a client reveals they drink 12 beers a day and had their
last drink 6 hours ago. The nurse should prioritize monitoring for which early sign of alcohol
withdrawal?
A. Visual hallucinations
B. Seizures
C. Fine tremors and tachycardia
D. Delirium Tremens
Answer: C
Rationale: Early symptoms of alcohol withdrawal typically begin within 6 to 8 hours after
the last drink and include tremors, anxiety, and tachycardia. Identifying these early signs
allows for the initiation of withdrawal protocols, such as CIWA, to prevent progression to
more severe stages like seizures or delirium. Close monitoring of vital signs is essential
during this initial period.
8. A nurse enters a room and finds a client with a history of depression sitting on the floor
crying. Which statement by the nurse demonstrates empathy?
A. Don’t cry; everything is going to be alright.
B. Why are you sitting on the floor? You’ll catch a cold.
C. It’s time for lunch, so let’s get you cleaned up.
D. I see that you are very upset; I will sit here with you for a while.
Answer: D
Rationale: Empathy involves acknowledging the client’s emotional state and offering a
supportive presence without judgment or false reassurance. Sitting with the client
(‘offering self’) is a powerful therapeutic tool that builds trust. This approach validates the
client’s feelings and shows that the nurse is willing to share in their experience.
9. A client is receiving Chlorpromazine and begins to experience muscle rigidity, a high fever
of 104.2°F, and an altered level of consciousness. The nurse should recognize these as signs
of:
A. Acute Dystonia
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of schizophrenia and is hearing
voices telling them to ‘hurt the others.’ Which is the priority nursing intervention?
A. Tell the client that the voices are not real and to ignore them.
B. Place the client in a seclusion room immediately for safety.
C. Ask the client what the voices are saying to assess for command hallucinations.
D. Administer a PRN dose of an anti-anxiety medication.
Answer: C
Rationale: Safety is the absolute priority when dealing with hallucinations that involve
potential harm. Identifying the specific content of command hallucinations allows the nurse
to implement appropriate safety precautions for the client and others. This assessment is
the first step in the nursing process before intervention or medication administration.
2. A nurse is caring for a client with Bipolar I Disorder who is experiencing an acute manic
episode. The client is pacing the hallway and refusing to sit for meals. Which nutritional
intervention is most appropriate?
A. Allow the client to eat in their room alone to reduce stimuli.
B. Provide high-calorie, high-protein finger foods that can be eaten while walking.
C. Place the client on a liquid diet to ensure hydration.
D. Wait until the manic episode subsides to offer nutrition.
Answer: B
Rationale: Clients in an acute manic state often have excessive physical activity and cannot
sit long enough to eat a full meal. Providing finger foods allows them to maintain necessary
caloric intake and hydration while remaining mobile. This intervention addresses the
physical need for energy without forcing the client into a restrictive environment that
might escalate agitation.
3. A client has been taking Lithium for two weeks to manage Bipolar Disorder. The client
reports blurred vision, severe diarrhea, and tremors. What is the nurse’s priority action?
A. Advise the client to increase their salt intake immediately.
B. Administer an antidiarrheal medication and reassess in four hours.
C. Document the findings as common side effects of early lithium therapy.
D. Instruct the client to withhold the next dose and prepare for a serum lithium level check.
,Answer: D
Rationale: The symptoms described are classic indicators of lithium toxicity, which can be
life-threatening if not addressed. Lithium has a narrow therapeutic index, so any signs of
toxicity require immediate cessation of the drug and laboratory verification. Prompt
intervention is necessary to prevent severe neurological damage or renal failure.
4. A nurse is performing a suicide risk assessment on a newly admitted client. The client
states, ‘I won’t be a problem for anyone much longer.’ How should the nurse respond?
A. Why do you feel like you are a problem?
B. Are you thinking of hurting or killing yourself?
C. You have so much to live for, things will get better.
D. I will make sure someone stays with you all the time.
Answer: B
Rationale: When a client makes a veiled suicide threat, the nurse must use direct and clear
language to assess for intent and plan. Vague responses or false reassurances are non-
therapeutic and may miss a critical window for intervention. Directly asking about suicidal
ideation is a standard safety protocol in mental health nursing.
5. A client diagnosed with Borderline Personality Disorder is angry at the primary nurse and
tells another nurse, ‘You are the only one who cares; my other nurse is incompetent.’ This
behavior is an example of:
A. Rationalization
B. Splitting
C. Reaction Formation
D. Displacement
Answer: B
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the individual views people as all good or all bad. This behavior often creates
conflict within the treatment team and is a way for the client to manage internal anxiety.
The nursing staff must maintain consistent boundaries and communicate frequently to
avoid being manipulated by this behavior.
6. A client is prescribed Clozapine for treatment-resistant schizophrenia. Which laboratory
result must the nurse monitor most closely?
A. Serum Potassium
B. Blood Urea Nitrogen (BUN)
C. White Blood Cell (WBC) count
, D. Hemoglobin A1c
Answer: C
Rationale: Clozapine carries a high risk of agranulocytosis, which is a severe and
potentially fatal drop in white blood cell counts. Regular monitoring of the WBC and
Absolute Neutrophil Count (ANC) is a legal and safety requirement for clients on this
medication. Nurses must educate clients to report any signs of infection, such as fever or
sore throat, immediately.
7. During an admission assessment, a client reveals they drink 12 beers a day and had their
last drink 6 hours ago. The nurse should prioritize monitoring for which early sign of alcohol
withdrawal?
A. Visual hallucinations
B. Seizures
C. Fine tremors and tachycardia
D. Delirium Tremens
Answer: C
Rationale: Early symptoms of alcohol withdrawal typically begin within 6 to 8 hours after
the last drink and include tremors, anxiety, and tachycardia. Identifying these early signs
allows for the initiation of withdrawal protocols, such as CIWA, to prevent progression to
more severe stages like seizures or delirium. Close monitoring of vital signs is essential
during this initial period.
8. A nurse enters a room and finds a client with a history of depression sitting on the floor
crying. Which statement by the nurse demonstrates empathy?
A. Don’t cry; everything is going to be alright.
B. Why are you sitting on the floor? You’ll catch a cold.
C. It’s time for lunch, so let’s get you cleaned up.
D. I see that you are very upset; I will sit here with you for a while.
Answer: D
Rationale: Empathy involves acknowledging the client’s emotional state and offering a
supportive presence without judgment or false reassurance. Sitting with the client
(‘offering self’) is a powerful therapeutic tool that builds trust. This approach validates the
client’s feelings and shows that the nurse is willing to share in their experience.
9. A client is receiving Chlorpromazine and begins to experience muscle rigidity, a high fever
of 104.2°F, and an altered level of consciousness. The nurse should recognize these as signs
of:
A. Acute Dystonia
