NUR 2459 Exam 2 Actual Exam V2 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
During the initial assessment, the client states, ‘I just don’t see any point in living anymore.’
Which action should the nurse take first?
A. Assure the client that things will get better soon.
B. Encourage the client to participate in group therapy sessions.
C. Document the client’s statement in the medical record.
D. Ask the client if they have a specific plan for self-harm.
Answer: D
Rationale: Safety is the highest priority when a client expresses hopelessness or suicidal
ideation. The nurse must immediately assess the lethality of the situation by asking about a
specific plan and access to means. This allows the treatment team to implement the
necessary level of suicide precautions.
2. A client diagnosed with Schizophrenia is standing in the hallway looking at the wall and
whispering, ‘I know you are trying to poison me.’ Which response by the nurse is most
therapeutic?
A. Nobody is trying to poison you; our food is tested for safety.
B. I don’t see anyone by the wall, but I can see that you are frightened.
C. Who exactly do you think is trying to poison you?
D. Why would anyone want to do that to you?
Answer: B
Rationale: This response acknowledges the client’s feelings without reinforcing the
hallucination or delusion. The nurse presents reality by stating they do not see anyone,
while validating the client’s emotional experience of fear. This approach helps build trust
while maintaining a grounding in reality.
3. A nurse is providing discharge teaching for a client prescribed Lithium Carbonate for
Bipolar Disorder. Which statement by the client indicates a need for further education?
A. I should significantly reduce my salt intake to prevent toxicity.
B. I will call my doctor if I experience excessive thirst or tremors.
C. I will make sure to drink at least 2 to 3 liters of water a day.
D. I will need to have my blood levels checked regularly.
,Answer: A
Rationale: Lithium is a salt, and its excretion is closely linked to sodium levels in the body.
If sodium intake is drastically reduced, the kidneys may retain lithium, leading to toxic
levels. Clients should be instructed to maintain a consistent, normal sodium intake and stay
well-hydrated.
4. A nurse is caring for a client experiencing a severe panic attack. The client is
hyperventilating and states, ‘I feel like I’m going to die.’ What is the priority nursing
intervention?
A. Explain the physiological causes of panic attacks to the client.
B. Instruct the client to take deep breaths into a paper bag.
C. Stay with the client and use a calm, low-pitched voice.
D. Leave the client alone to provide privacy during the episode.
Answer: C
Rationale: The nurse’s presence provides a sense of security for a client who feels out of
control during a panic attack. Using a calm and quiet voice helps to de-escalate the situation
and prevent further anxiety. Minimal, clear instructions are more effective than complex
explanations when a client’s anxiety is at a panic level.
5. A client with Obsessive-Compulsive Disorder (OCD) spends two hours each morning
arranging items on their nightstand. How should the nurse manage this behavior in the initial
phase of treatment?
A. Allow the client enough time to perform the ritual to reduce anxiety.
B. Prevent the client from touching the items to break the habit.
C. Explain that the behavior is irrational and time-consuming.
D. Provide a distraction task to stop the rituals immediately.
Answer: A
Rationale: In the early stages of treatment for OCD, rituals should be allowed because they
serve as a coping mechanism to manage intense anxiety. Suddenly stopping rituals can lead
to a panic-level anxiety response. The goal of treatment is to gradually reduce the time
spent on rituals while introducing new coping strategies.
6. A client is being treated with Phenelzine (Nardil), an MAOI, for depression. Which food
choice from the hospital menu should the nurse intervene on?
A. Pepperoni pizza with aged cheddar cheese.
B. Grilled chicken breast with steamed broccoli.
C. Fresh tossed salad with oil and vinegar.
, D. Baked potato with sour cream and chives.
Answer: A
Rationale: Clients taking MAOIs must avoid foods high in tyramine, such as aged cheeses
and cured meats like pepperoni. Consumption of these foods can lead to a hypertensive
crisis, which is a medical emergency. Education regarding a low-tyramine diet is a critical
safety component of MAOI therapy.
7. A nurse is assessing a client for Bipolar I Disorder who is currently in a manic phase. Which
clinical manifestation should the nurse expect to observe?
A. Sleeping for more than 10 hours per night.
B. Increased focus and attention to detail.
C. Decreased interest in pleasurable activities.
D. Flight of ideas and pressured speech.
Answer: D
Rationale: Mania is characterized by a distinct period of abnormally elevated or irritable
mood, often accompanied by pressured speech and flight of ideas. Clients in a manic phase
typically have a decreased need for sleep and exhibit distractibility rather than focus. These
behaviors often lead to social and occupational impairment.
8. A client is prescribed Clozapine (Clozaril) for treatment-resistant schizophrenia. Which
laboratory result must the nurse monitor most closely?
A. Serum potassium levels.
B. White blood cell (WBC) count.
C. Blood urea nitrogen (BUN).
D. Prothrombin time (PT).
Answer: B
Rationale: Clozapine can cause agranulocytosis, a life-threatening decline in white blood
cells. Strict protocols require regular WBC monitoring to ensure the client is not developing
this condition. If the WBC count falls below a certain threshold, the medication must be
discontinued immediately.
9. A client who recently lost their spouse says, ‘I feel like I’m going crazy. I keep hearing my
spouse’s voice in the house.’ What is the most appropriate response by the nurse?
A. You are experiencing auditory hallucinations and need medication.
B. It is common to experience sensory perceptions of a loved one shortly after their death.
C. You should try to ignore the voice so you can move on with your life.
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of Major Depressive Disorder.
During the initial assessment, the client states, ‘I just don’t see any point in living anymore.’
Which action should the nurse take first?
A. Assure the client that things will get better soon.
B. Encourage the client to participate in group therapy sessions.
C. Document the client’s statement in the medical record.
D. Ask the client if they have a specific plan for self-harm.
Answer: D
Rationale: Safety is the highest priority when a client expresses hopelessness or suicidal
ideation. The nurse must immediately assess the lethality of the situation by asking about a
specific plan and access to means. This allows the treatment team to implement the
necessary level of suicide precautions.
2. A client diagnosed with Schizophrenia is standing in the hallway looking at the wall and
whispering, ‘I know you are trying to poison me.’ Which response by the nurse is most
therapeutic?
A. Nobody is trying to poison you; our food is tested for safety.
B. I don’t see anyone by the wall, but I can see that you are frightened.
C. Who exactly do you think is trying to poison you?
D. Why would anyone want to do that to you?
Answer: B
Rationale: This response acknowledges the client’s feelings without reinforcing the
hallucination or delusion. The nurse presents reality by stating they do not see anyone,
while validating the client’s emotional experience of fear. This approach helps build trust
while maintaining a grounding in reality.
3. A nurse is providing discharge teaching for a client prescribed Lithium Carbonate for
Bipolar Disorder. Which statement by the client indicates a need for further education?
A. I should significantly reduce my salt intake to prevent toxicity.
B. I will call my doctor if I experience excessive thirst or tremors.
C. I will make sure to drink at least 2 to 3 liters of water a day.
D. I will need to have my blood levels checked regularly.
,Answer: A
Rationale: Lithium is a salt, and its excretion is closely linked to sodium levels in the body.
If sodium intake is drastically reduced, the kidneys may retain lithium, leading to toxic
levels. Clients should be instructed to maintain a consistent, normal sodium intake and stay
well-hydrated.
4. A nurse is caring for a client experiencing a severe panic attack. The client is
hyperventilating and states, ‘I feel like I’m going to die.’ What is the priority nursing
intervention?
A. Explain the physiological causes of panic attacks to the client.
B. Instruct the client to take deep breaths into a paper bag.
C. Stay with the client and use a calm, low-pitched voice.
D. Leave the client alone to provide privacy during the episode.
Answer: C
Rationale: The nurse’s presence provides a sense of security for a client who feels out of
control during a panic attack. Using a calm and quiet voice helps to de-escalate the situation
and prevent further anxiety. Minimal, clear instructions are more effective than complex
explanations when a client’s anxiety is at a panic level.
5. A client with Obsessive-Compulsive Disorder (OCD) spends two hours each morning
arranging items on their nightstand. How should the nurse manage this behavior in the initial
phase of treatment?
A. Allow the client enough time to perform the ritual to reduce anxiety.
B. Prevent the client from touching the items to break the habit.
C. Explain that the behavior is irrational and time-consuming.
D. Provide a distraction task to stop the rituals immediately.
Answer: A
Rationale: In the early stages of treatment for OCD, rituals should be allowed because they
serve as a coping mechanism to manage intense anxiety. Suddenly stopping rituals can lead
to a panic-level anxiety response. The goal of treatment is to gradually reduce the time
spent on rituals while introducing new coping strategies.
6. A client is being treated with Phenelzine (Nardil), an MAOI, for depression. Which food
choice from the hospital menu should the nurse intervene on?
A. Pepperoni pizza with aged cheddar cheese.
B. Grilled chicken breast with steamed broccoli.
C. Fresh tossed salad with oil and vinegar.
, D. Baked potato with sour cream and chives.
Answer: A
Rationale: Clients taking MAOIs must avoid foods high in tyramine, such as aged cheeses
and cured meats like pepperoni. Consumption of these foods can lead to a hypertensive
crisis, which is a medical emergency. Education regarding a low-tyramine diet is a critical
safety component of MAOI therapy.
7. A nurse is assessing a client for Bipolar I Disorder who is currently in a manic phase. Which
clinical manifestation should the nurse expect to observe?
A. Sleeping for more than 10 hours per night.
B. Increased focus and attention to detail.
C. Decreased interest in pleasurable activities.
D. Flight of ideas and pressured speech.
Answer: D
Rationale: Mania is characterized by a distinct period of abnormally elevated or irritable
mood, often accompanied by pressured speech and flight of ideas. Clients in a manic phase
typically have a decreased need for sleep and exhibit distractibility rather than focus. These
behaviors often lead to social and occupational impairment.
8. A client is prescribed Clozapine (Clozaril) for treatment-resistant schizophrenia. Which
laboratory result must the nurse monitor most closely?
A. Serum potassium levels.
B. White blood cell (WBC) count.
C. Blood urea nitrogen (BUN).
D. Prothrombin time (PT).
Answer: B
Rationale: Clozapine can cause agranulocytosis, a life-threatening decline in white blood
cells. Strict protocols require regular WBC monitoring to ensure the client is not developing
this condition. If the WBC count falls below a certain threshold, the medication must be
discontinued immediately.
9. A client who recently lost their spouse says, ‘I feel like I’m going crazy. I keep hearing my
spouse’s voice in the house.’ What is the most appropriate response by the nurse?
A. You are experiencing auditory hallucinations and need medication.
B. It is common to experience sensory perceptions of a loved one shortly after their death.
C. You should try to ignore the voice so you can move on with your life.
