NUR 2459 Exam 2 Actual Exam V2 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client is admitted involuntarily to the psychiatric unit after threatening to harm a
neighbor. Which statement regarding the client’s rights is most accurate?
A. The client has lost the right to refuse psychotropic medications.
B. The client is considered legally incompetent due to the involuntary status.
C. The client no longer has the right to file a writ of habeas corpus.
D. The client retains the right to give informed consent for all treatments.
Answer: D
Rationale: Involuntary admission does not automatically equate to legal incompetence.
Clients still retain their civil rights, including the right to refuse medication and provide
informed consent unless a court has specifically ruled otherwise. The nurse must recognize
that being a danger to others justifies the admission but not the immediate stripping of
legal autonomy.
2. A nurse is caring for a client with Major Depressive Disorder who states, ‘Everything is a
failure, and I am just a burden to everyone.’ Which response by the nurse is therapeutic?
A. It sounds like you are feeling very discouraged right now.
B. I am sure things will get better once the medication kicks in.
C. Why do you feel that way when your family loves you?
D. You should focus on the positive aspects of your life.
Answer: A
Rationale: This response uses the therapeutic technique of reflection and validation of the
client’s feelings. It avoids ‘why’ questions, which can be perceived as accusatory, and steers
clear of false reassurance. By acknowledging the client’s despair, the nurse fosters a
trusting environment for further communication.
3. A client diagnosed with Bipolar I Disorder is in a state of acute mania, pacing the halls and
talking rapidly. Which nutritional intervention is most appropriate?
A. Allowing the client to eat in the dining hall with other patients.
B. Ordering a strictly liquid diet to prevent choking.
C. Providing high-calorie, high-protein finger foods.
D. Scheduling three large formal meals in a quiet room.
,Answer: C
Rationale: Clients in an acute manic phase are often too hyperactive to sit down for a full
meal, leading to significant weight loss and exhaustion. Finger foods allow the client to
consume necessary calories and protein while remaining mobile. This strategy prioritizes
physiological needs while accommodating the symptoms of the disorder.
4. A nurse is monitoring a client taking Lithium Carbonate. The client reports blurred vision,
coarse tremors, and severe diarrhea. What is the nurse’s priority action?
A. Request a stat ECG from the provider.
B. Hold the medication and notify the healthcare provider.
C. Administer the next scheduled dose as planned.
D. Encourage the client to increase sodium intake immediately.
Answer: B
Rationale: Coarse tremors and blurred vision are signs of moderate to severe lithium
toxicity, which can lead to seizures or death. The nurse must stop the medication
immediately to prevent further accumulation of the drug in the system. Notifying the
provider is essential to obtain a serum lithium level and initiate emergency care if needed.
5. A client with schizophrenia is hearing voices telling them that the food is poisoned. Which
nursing intervention is most effective for this delusion?
A. Tasting the food in front of the client to prove it is safe.
B. Explaining logically that the kitchen staff would not poison patients.
C. Providing pre-packaged, unopened food containers.
D. Confronting the client about the irrationality of the belief.
Answer: C
Rationale: Using unopened or pre-packaged food can help decrease the client’s paranoia
and ensure nutritional intake without challenging the delusion directly. Direct
confrontation or trying to prove the client wrong often reinforces the delusion or increases
anxiety. This intervention meets the client where they are while addressing the physical
need for nourishment.
6. A client is prescribed Sertraline for depression. Which statement by the client indicates a
need for further teaching?
A. I will stop taking the medicine if I feel better in two weeks.
B. I might feel a bit drowsy or have a headache at first.
C. I should call my doctor if I have thoughts of hurting myself.
, D. It may take several weeks before I notice a full effect on my mood.
Answer: A
Rationale: Antidepressants must be tapered slowly and never stopped abruptly to avoid
withdrawal symptoms or a relapse of depression. It is critical for the client to understand
that consistent use is required even after symptoms improve. Education should emphasize
the long-term nature of psychiatric medication management.
7. Which assessment finding is a hallmark of Neuroleptic Malignant Syndrome (NMS)?
A. Hypothermia and bradycardia.
B. Severe muscle rigidity and hyperpyrexia.
C. Muscle flaccidity and hypotension.
D. Increased appetite and sedation.
Answer: B
Rationale: NMS is a life-threatening reaction to antipsychotic medications characterized
by high fever (hyperpyrexia), muscular rigidity, and autonomic instability. This is a medical
emergency that requires immediate cessation of the causative agent and supportive care.
Nurses must be vigilant in monitoring vital signs and muscle tone in patients on
neuroleptics.
8. A client with Borderline Personality Disorder is being treated on the unit. The client tells
Nurse A, ‘You are the only one who cares; Nurse B is mean and incompetent.’ What is the
nurse’s best response?
A. Thank you, I try my best to be the best nurse for you.
B. All the nurses here are part of your treatment team.
C. I will talk to Nurse B about her behavior toward you.
D. Why do you think Nurse B is mean to you?
Answer: B
Rationale: This response addresses ‘splitting,’ a common defense mechanism in Borderline
Personality Disorder where the client views staff as all good or all bad. By asserting that the
entire staff is a unified team, the nurse avoids being manipulated into a ‘good’ role. This
maintains professional boundaries and discourages the client’s attempts to polarize the
staff.
9. A client is experiencing a panic attack. The client is tachypneic, hyperventilating, and
clutching their chest. Which action should the nurse take first?
A. Teach the client a new deep breathing technique.
B. Stay with the client and use short, simple sentences.
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client is admitted involuntarily to the psychiatric unit after threatening to harm a
neighbor. Which statement regarding the client’s rights is most accurate?
A. The client has lost the right to refuse psychotropic medications.
B. The client is considered legally incompetent due to the involuntary status.
C. The client no longer has the right to file a writ of habeas corpus.
D. The client retains the right to give informed consent for all treatments.
Answer: D
Rationale: Involuntary admission does not automatically equate to legal incompetence.
Clients still retain their civil rights, including the right to refuse medication and provide
informed consent unless a court has specifically ruled otherwise. The nurse must recognize
that being a danger to others justifies the admission but not the immediate stripping of
legal autonomy.
2. A nurse is caring for a client with Major Depressive Disorder who states, ‘Everything is a
failure, and I am just a burden to everyone.’ Which response by the nurse is therapeutic?
A. It sounds like you are feeling very discouraged right now.
B. I am sure things will get better once the medication kicks in.
C. Why do you feel that way when your family loves you?
D. You should focus on the positive aspects of your life.
Answer: A
Rationale: This response uses the therapeutic technique of reflection and validation of the
client’s feelings. It avoids ‘why’ questions, which can be perceived as accusatory, and steers
clear of false reassurance. By acknowledging the client’s despair, the nurse fosters a
trusting environment for further communication.
3. A client diagnosed with Bipolar I Disorder is in a state of acute mania, pacing the halls and
talking rapidly. Which nutritional intervention is most appropriate?
A. Allowing the client to eat in the dining hall with other patients.
B. Ordering a strictly liquid diet to prevent choking.
C. Providing high-calorie, high-protein finger foods.
D. Scheduling three large formal meals in a quiet room.
,Answer: C
Rationale: Clients in an acute manic phase are often too hyperactive to sit down for a full
meal, leading to significant weight loss and exhaustion. Finger foods allow the client to
consume necessary calories and protein while remaining mobile. This strategy prioritizes
physiological needs while accommodating the symptoms of the disorder.
4. A nurse is monitoring a client taking Lithium Carbonate. The client reports blurred vision,
coarse tremors, and severe diarrhea. What is the nurse’s priority action?
A. Request a stat ECG from the provider.
B. Hold the medication and notify the healthcare provider.
C. Administer the next scheduled dose as planned.
D. Encourage the client to increase sodium intake immediately.
Answer: B
Rationale: Coarse tremors and blurred vision are signs of moderate to severe lithium
toxicity, which can lead to seizures or death. The nurse must stop the medication
immediately to prevent further accumulation of the drug in the system. Notifying the
provider is essential to obtain a serum lithium level and initiate emergency care if needed.
5. A client with schizophrenia is hearing voices telling them that the food is poisoned. Which
nursing intervention is most effective for this delusion?
A. Tasting the food in front of the client to prove it is safe.
B. Explaining logically that the kitchen staff would not poison patients.
C. Providing pre-packaged, unopened food containers.
D. Confronting the client about the irrationality of the belief.
Answer: C
Rationale: Using unopened or pre-packaged food can help decrease the client’s paranoia
and ensure nutritional intake without challenging the delusion directly. Direct
confrontation or trying to prove the client wrong often reinforces the delusion or increases
anxiety. This intervention meets the client where they are while addressing the physical
need for nourishment.
6. A client is prescribed Sertraline for depression. Which statement by the client indicates a
need for further teaching?
A. I will stop taking the medicine if I feel better in two weeks.
B. I might feel a bit drowsy or have a headache at first.
C. I should call my doctor if I have thoughts of hurting myself.
, D. It may take several weeks before I notice a full effect on my mood.
Answer: A
Rationale: Antidepressants must be tapered slowly and never stopped abruptly to avoid
withdrawal symptoms or a relapse of depression. It is critical for the client to understand
that consistent use is required even after symptoms improve. Education should emphasize
the long-term nature of psychiatric medication management.
7. Which assessment finding is a hallmark of Neuroleptic Malignant Syndrome (NMS)?
A. Hypothermia and bradycardia.
B. Severe muscle rigidity and hyperpyrexia.
C. Muscle flaccidity and hypotension.
D. Increased appetite and sedation.
Answer: B
Rationale: NMS is a life-threatening reaction to antipsychotic medications characterized
by high fever (hyperpyrexia), muscular rigidity, and autonomic instability. This is a medical
emergency that requires immediate cessation of the causative agent and supportive care.
Nurses must be vigilant in monitoring vital signs and muscle tone in patients on
neuroleptics.
8. A client with Borderline Personality Disorder is being treated on the unit. The client tells
Nurse A, ‘You are the only one who cares; Nurse B is mean and incompetent.’ What is the
nurse’s best response?
A. Thank you, I try my best to be the best nurse for you.
B. All the nurses here are part of your treatment team.
C. I will talk to Nurse B about her behavior toward you.
D. Why do you think Nurse B is mean to you?
Answer: B
Rationale: This response addresses ‘splitting,’ a common defense mechanism in Borderline
Personality Disorder where the client views staff as all good or all bad. By asserting that the
entire staff is a unified team, the nurse avoids being manipulated into a ‘good’ role. This
maintains professional boundaries and discourages the client’s attempts to polarize the
staff.
9. A client is experiencing a panic attack. The client is tachypneic, hyperventilating, and
clutching their chest. Which action should the nurse take first?
A. Teach the client a new deep breathing technique.
B. Stay with the client and use short, simple sentences.
