NUR 2459 Exam 2 Actual Exam V1 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of severe anxiety. The nurse
observes the client pacing the floor, breathing rapidly, and reporting feelings of ‘impending
doom.’ Which nursing intervention is the priority at this time?
A. Instruct the client on deep breathing exercises and progressive muscle relaxation.
B. Stay with the client and provide a calm, quiet environment.
C. Ask the client to identify the stressors that led to the current state.
D. Encourage the client to join a group therapy session to distract from anxiety.
Answer: B
Rationale: During severe anxiety or panic levels, the client is unable to process complex
information or learn new coping skills. Staying with the client ensures their safety and
provides a sense of security while the nurse models calmness. Environmental stimuli
should be minimized to prevent further escalation of symptoms.
2. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends several
hours a day washing their hands. What is the most appropriate initial nursing intervention for
this client?
A. Forbid the client from using the sink for the first 48 hours of admission.
B. Provide a structured schedule that allows time for the ritual initially.
C. Point out the irrationality of the behavior every time the client washes their hands.
D. Increase the frequency of handwashing to induce a sense of boredom in the client.
Answer: B
Rationale: Initially, the nurse should allow the client to perform rituals to prevent
overwhelming anxiety. Setting a schedule provides a sense of control and safety within the
therapeutic environment. Over time, the nurse will work with the client to gradually limit
the time spent on rituals as healthier coping mechanisms are developed.
3. A client diagnosed with Post-Traumatic Stress Disorder (PTSD) reports experiencing
frequent flashbacks and nightmares. Which medication class is most commonly prescribed as
a first-line treatment for these symptoms?
A. Selective Serotonin Reuptake Inhibitors (SSRIs)
B. Benzodiazepines
C. First-generation Antipsychotics
,D. Tricyclic Antidepressants
Answer: A
Rationale: SSRIs such as sertraline or paroxetine are considered the gold standard for
long-term pharmacological management of PTSD. They help regulate mood and reduce the
frequency of intrusive thoughts, flashbacks, and avoidance behaviors. Benzodiazepines are
generally avoided in PTSD due to the high risk of substance misuse and their potential to
interfere with cognitive processing of trauma.
4. A client with Anorexia Nervosa is being admitted to an inpatient unit. Which physical
assessment finding requires immediate notification of the healthcare provider?
A. Presence of lanugo on the back and arms.
B. Amenorrhea for the past six months.
C. A heart rate of 38 beats per minute.
D. A Body Mass Index (BMI) of 16.5.
Answer: C
Rationale: Severe bradycardia (heart rate less than 40 bpm) indicates significant
cardiovascular compromise and the risk of sudden cardiac arrest. While amenorrhea and
lanugo are common findings in Anorexia, they are not immediate life-threats. The nurse
must prioritize physiological stability when prioritizing care for eating disorder patients.
5. A client with Borderline Personality Disorder (BPD) tells nurse A, ‘You are the only nurse
who understands me; the night shift nurse is terrible and incompetent.’ How should nurse A
respond?
A. Discuss the client’s treatment plan during the multidisciplinary team meeting.
B. Agree that the night shift nurse can be difficult sometimes.
C. Encourage the client to discuss these concerns directly with the night shift nurse.
D. Thank the client for the compliment and promise to stay on their case.
Answer: A
Rationale: The client is demonstrating ‘splitting,’ a common defense mechanism in BPD
where individuals perceive others as all good or all bad. The nursing team must maintain a
unified approach to prevent being manipulated or divided. Consistency in communication
and boundaries among all staff members is essential for effective treatment.
6. A nurse is teaching a client about a new prescription for Buspirone for Generalized Anxiety
Disorder. Which statement by the client indicates a need for further teaching?
A. I can take this medication whenever I feel a panic attack starting.
B. I should avoid drinking grapefruit juice while taking this medication.
, C. It may take 2 to 4 weeks before I feel the full effect of this medicine.
D. This medication is less likely to make me sleepy than Xanax.
Answer: A
Rationale: Buspirone is not an ‘as-needed’ (PRN) medication; it must be taken daily to
maintain therapeutic levels and is used for chronic anxiety. It differs from benzodiazepines
because it does not have immediate effects and does not cause significant sedation or
dependence. Clients must be educated that delayed onset is expected and consistency is
key.
7. A client is admitted for Somatic Symptom Disorder. The client frequently complains of
chest pain, but all diagnostic tests have been negative. What is the most appropriate nursing
goal?
A. The client will admit that the pain is purely psychological.
B. The client will identify the relationship between stress and physical symptoms.
C. The client will verbalize understanding that diagnostic tests are foolproof.
D. The client will stop requesting pain medication from the staff.
Answer: B
Rationale: Modern psychiatric nursing for somatic disorders focuses on helping the client
recognize emotional triggers for physical pain. Forcing the client to admit the pain is ‘fake’
is counterproductive, as the client actually perceives the discomfort. The goal is to shift the
focus from physical symptoms to emotional processing and coping skills.
8. A nurse is performing an assessment on a client suspected of having Bulimia Nervosa.
Which physical finding is highly suggestive of this condition?
A. Severe weight loss leading to emaciation.
B. Consistent high blood pressure readings.
C. Brittle hair and nails.
D. Enlarged parotid glands.
Answer: D
Rationale: Enlarged parotid glands (sialadenosis) occur in Bulimia due to repeated
vomiting and overstimulation of the salivary glands. Dentition destruction and Russell’s
sign (calluses on knuckles) are also key indicators. Unlike Anorexia, clients with Bulimia
often maintain a weight that is close to or slightly above normal.
9. A client with Antisocial Personality Disorder is hospitalized. Which behavior should the
nurse expect to see?
A. Social withdrawal and extreme shyness.
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A client is admitted to the psychiatric unit with a diagnosis of severe anxiety. The nurse
observes the client pacing the floor, breathing rapidly, and reporting feelings of ‘impending
doom.’ Which nursing intervention is the priority at this time?
A. Instruct the client on deep breathing exercises and progressive muscle relaxation.
B. Stay with the client and provide a calm, quiet environment.
C. Ask the client to identify the stressors that led to the current state.
D. Encourage the client to join a group therapy session to distract from anxiety.
Answer: B
Rationale: During severe anxiety or panic levels, the client is unable to process complex
information or learn new coping skills. Staying with the client ensures their safety and
provides a sense of security while the nurse models calmness. Environmental stimuli
should be minimized to prevent further escalation of symptoms.
2. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends several
hours a day washing their hands. What is the most appropriate initial nursing intervention for
this client?
A. Forbid the client from using the sink for the first 48 hours of admission.
B. Provide a structured schedule that allows time for the ritual initially.
C. Point out the irrationality of the behavior every time the client washes their hands.
D. Increase the frequency of handwashing to induce a sense of boredom in the client.
Answer: B
Rationale: Initially, the nurse should allow the client to perform rituals to prevent
overwhelming anxiety. Setting a schedule provides a sense of control and safety within the
therapeutic environment. Over time, the nurse will work with the client to gradually limit
the time spent on rituals as healthier coping mechanisms are developed.
3. A client diagnosed with Post-Traumatic Stress Disorder (PTSD) reports experiencing
frequent flashbacks and nightmares. Which medication class is most commonly prescribed as
a first-line treatment for these symptoms?
A. Selective Serotonin Reuptake Inhibitors (SSRIs)
B. Benzodiazepines
C. First-generation Antipsychotics
,D. Tricyclic Antidepressants
Answer: A
Rationale: SSRIs such as sertraline or paroxetine are considered the gold standard for
long-term pharmacological management of PTSD. They help regulate mood and reduce the
frequency of intrusive thoughts, flashbacks, and avoidance behaviors. Benzodiazepines are
generally avoided in PTSD due to the high risk of substance misuse and their potential to
interfere with cognitive processing of trauma.
4. A client with Anorexia Nervosa is being admitted to an inpatient unit. Which physical
assessment finding requires immediate notification of the healthcare provider?
A. Presence of lanugo on the back and arms.
B. Amenorrhea for the past six months.
C. A heart rate of 38 beats per minute.
D. A Body Mass Index (BMI) of 16.5.
Answer: C
Rationale: Severe bradycardia (heart rate less than 40 bpm) indicates significant
cardiovascular compromise and the risk of sudden cardiac arrest. While amenorrhea and
lanugo are common findings in Anorexia, they are not immediate life-threats. The nurse
must prioritize physiological stability when prioritizing care for eating disorder patients.
5. A client with Borderline Personality Disorder (BPD) tells nurse A, ‘You are the only nurse
who understands me; the night shift nurse is terrible and incompetent.’ How should nurse A
respond?
A. Discuss the client’s treatment plan during the multidisciplinary team meeting.
B. Agree that the night shift nurse can be difficult sometimes.
C. Encourage the client to discuss these concerns directly with the night shift nurse.
D. Thank the client for the compliment and promise to stay on their case.
Answer: A
Rationale: The client is demonstrating ‘splitting,’ a common defense mechanism in BPD
where individuals perceive others as all good or all bad. The nursing team must maintain a
unified approach to prevent being manipulated or divided. Consistency in communication
and boundaries among all staff members is essential for effective treatment.
6. A nurse is teaching a client about a new prescription for Buspirone for Generalized Anxiety
Disorder. Which statement by the client indicates a need for further teaching?
A. I can take this medication whenever I feel a panic attack starting.
B. I should avoid drinking grapefruit juice while taking this medication.
, C. It may take 2 to 4 weeks before I feel the full effect of this medicine.
D. This medication is less likely to make me sleepy than Xanax.
Answer: A
Rationale: Buspirone is not an ‘as-needed’ (PRN) medication; it must be taken daily to
maintain therapeutic levels and is used for chronic anxiety. It differs from benzodiazepines
because it does not have immediate effects and does not cause significant sedation or
dependence. Clients must be educated that delayed onset is expected and consistency is
key.
7. A client is admitted for Somatic Symptom Disorder. The client frequently complains of
chest pain, but all diagnostic tests have been negative. What is the most appropriate nursing
goal?
A. The client will admit that the pain is purely psychological.
B. The client will identify the relationship between stress and physical symptoms.
C. The client will verbalize understanding that diagnostic tests are foolproof.
D. The client will stop requesting pain medication from the staff.
Answer: B
Rationale: Modern psychiatric nursing for somatic disorders focuses on helping the client
recognize emotional triggers for physical pain. Forcing the client to admit the pain is ‘fake’
is counterproductive, as the client actually perceives the discomfort. The goal is to shift the
focus from physical symptoms to emotional processing and coping skills.
8. A nurse is performing an assessment on a client suspected of having Bulimia Nervosa.
Which physical finding is highly suggestive of this condition?
A. Severe weight loss leading to emaciation.
B. Consistent high blood pressure readings.
C. Brittle hair and nails.
D. Enlarged parotid glands.
Answer: D
Rationale: Enlarged parotid glands (sialadenosis) occur in Bulimia due to repeated
vomiting and overstimulation of the salivary glands. Dentition destruction and Russell’s
sign (calluses on knuckles) are also key indicators. Unlike Anorexia, clients with Bulimia
often maintain a weight that is close to or slightly above normal.
9. A client with Antisocial Personality Disorder is hospitalized. Which behavior should the
nurse expect to see?
A. Social withdrawal and extreme shyness.
