NUR 2459 Exam 2 Actual Exam V1 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A nurse is monitoring a patient with a lithium level of 1.8 mEq/L. Which action should the
nurse prioritize?
A. Administer the next dose as scheduled
B. Hold the medication and notify the provider immediately
C. Increase oral fluid intake to 3 liters per day
D. Encourage the patient to rest in a dark room
Answer: B
Rationale: A lithium level of 1.8 mEq/L indicates moderate toxicity, as the therapeutic
range is generally 0.6 to 1.2 mEq/L. The nurse must immediately hold the medication to
prevent further accumulation and potential permanent organ damage. Close monitoring for
symptoms such as vomiting, diarrhea, and coarse tremors is essential during this period.
2. A patient diagnosed with Major Depressive Disorder expresses feelings of worthlessness
and says, ‘Nothing matters anymore.’ What is the most appropriate nursing response?
A. Are you thinking about hurting yourself or ending your life?
B. You have so much to live for, don’t say that.
C. I am sure you will feel better once your medication starts working.
D. Why do you feel that nothing matters anymore?
Answer: A
Rationale: When a patient expresses hopelessness, the nurse’s priority is to assess for
suicidal ideation or intent. Directly asking about self-harm provides clear data and ensures
patient safety. This intervention follows the nursing process by prioritizing safety and
assessment over false reassurance or closed-ended questioning.
3. Which clinical manifestation would a nurse expect to see in a patient experiencing
Neuroleptic Malignant Syndrome (NMS)?
A. Hypotension and bradycardia
B. Extreme muscle rigidity and high fever
C. Excessive salivation and runny nose
D. Increased appetite and weight gain
Answer: B
,Rationale: Neuroleptic Malignant Syndrome is a life-threatening emergency characterized
by ‘lead pipe’ muscle rigidity and hyperpyrexia. Patients also frequently exhibit autonomic
instability and altered mental status. Rapid recognition and discontinuation of
antipsychotic medication are critical steps in managing this condition.
4. A nurse is caring for a patient in the manic phase of Bipolar Disorder. Which meal choice is
most appropriate for this patient?
A. A turkey sandwich and an apple
B. A bowl of hot vegetable soup
C. Spaghetti and meatballs with a side salad
D. Steak and mashed potatoes
Answer: A
Rationale: Patients in a manic state are often too hyperactive to sit down for a formal meal.
Finger foods that can be eaten while walking allow the patient to maintain adequate caloric
intake despite their high activity levels. Providing high-protein, high-calorie portable foods
is a standard nursing intervention for mania.
5. A patient recently started on Fluoxetine (Prozac) reports experiencing a rapid heartbeat,
sweating, and muscle spasms. What should the nurse suspect?
A. Serotonin Syndrome
B. Normal side effects of SSRIs
C. Anticholinergic crisis
D. Hypertensive crisis
Answer: A
Rationale: Serotonin syndrome is a potentially fatal condition caused by excessive
serotonin levels, often occurring when starting or increasing doses of SSRIs. Symptoms
include tachycardia, diaphoresis, hyperreflexia, and mental status changes. The nurse must
discontinue the offending agent and provide supportive care to manage symptoms.
6. Which statement by a patient taking Phenelzine (Nardil) indicates a need for further
teaching?
A. I will check with my pharmacist before taking cold medicine.
B. I should avoid eating aged cheeses and smoked meats.
C. I can have a glass of red wine with dinner occasionally.
D. I need to monitor my blood pressure regularly.
Answer: C
, Rationale: Phenelzine is an MAOI, which requires a strict tyramine-free diet to prevent a
hypertensive crisis. Red wine, aged cheeses, and cured meats are high in tyramine and
must be avoided completely. Educating the patient on these dietary restrictions is vital for
their safety while on this medication.
7. A patient with schizophrenia states, ‘The FBI is monitoring my thoughts through the
television.’ How should the nurse respond?
A. It sounds like you are feeling frightened by these thoughts.
B. I believe you, tell me more about what they are doing.
C. The FBI does not have the technology to do that.
D. Why do you think the FBI is interested in you?
Answer: A
Rationale: The nurse should acknowledge the patient’s feelings without validating the
delusion itself. This approach uses empathy to build rapport while remaining grounded in
reality. Directly arguing with a delusion is counterproductive and can damage the
therapeutic relationship.
8. A nurse is caring for a patient with severe Generalized Anxiety Disorder. Which
intervention is most effective during an acute anxiety attack?
A. Leave the patient alone to allow them space to calm down.
B. Encourage the patient to discuss the root cause of their anxiety.
C. Instruct the patient to use slow, deep abdominal breathing.
D. Teach the patient about long-term coping mechanisms.
Answer: C
Rationale: During an acute attack, the patient’s focus is limited, making complex teaching
or deep discussion ineffective. Deep breathing helps physiological stabilization and
provides a simple task for the patient to focus on. Staying with the patient and providing a
calm, quiet environment is also essential for safety.
9. A patient with OCD is late for a group session because they spent two hours washing their
hands. What is the most appropriate nursing intervention?
A. Prohibit the patient from washing their hands before group.
B. Ignore the behavior so the patient does not feel embarrassed.
C. Inform the patient that their behavior is disruptive to others.
D. Allow the ritual initially but gradually limit the time allowed.
Answer: D
Health Nursing (NUR2459 Exam 2) | Rasmussen
1. A nurse is monitoring a patient with a lithium level of 1.8 mEq/L. Which action should the
nurse prioritize?
A. Administer the next dose as scheduled
B. Hold the medication and notify the provider immediately
C. Increase oral fluid intake to 3 liters per day
D. Encourage the patient to rest in a dark room
Answer: B
Rationale: A lithium level of 1.8 mEq/L indicates moderate toxicity, as the therapeutic
range is generally 0.6 to 1.2 mEq/L. The nurse must immediately hold the medication to
prevent further accumulation and potential permanent organ damage. Close monitoring for
symptoms such as vomiting, diarrhea, and coarse tremors is essential during this period.
2. A patient diagnosed with Major Depressive Disorder expresses feelings of worthlessness
and says, ‘Nothing matters anymore.’ What is the most appropriate nursing response?
A. Are you thinking about hurting yourself or ending your life?
B. You have so much to live for, don’t say that.
C. I am sure you will feel better once your medication starts working.
D. Why do you feel that nothing matters anymore?
Answer: A
Rationale: When a patient expresses hopelessness, the nurse’s priority is to assess for
suicidal ideation or intent. Directly asking about self-harm provides clear data and ensures
patient safety. This intervention follows the nursing process by prioritizing safety and
assessment over false reassurance or closed-ended questioning.
3. Which clinical manifestation would a nurse expect to see in a patient experiencing
Neuroleptic Malignant Syndrome (NMS)?
A. Hypotension and bradycardia
B. Extreme muscle rigidity and high fever
C. Excessive salivation and runny nose
D. Increased appetite and weight gain
Answer: B
,Rationale: Neuroleptic Malignant Syndrome is a life-threatening emergency characterized
by ‘lead pipe’ muscle rigidity and hyperpyrexia. Patients also frequently exhibit autonomic
instability and altered mental status. Rapid recognition and discontinuation of
antipsychotic medication are critical steps in managing this condition.
4. A nurse is caring for a patient in the manic phase of Bipolar Disorder. Which meal choice is
most appropriate for this patient?
A. A turkey sandwich and an apple
B. A bowl of hot vegetable soup
C. Spaghetti and meatballs with a side salad
D. Steak and mashed potatoes
Answer: A
Rationale: Patients in a manic state are often too hyperactive to sit down for a formal meal.
Finger foods that can be eaten while walking allow the patient to maintain adequate caloric
intake despite their high activity levels. Providing high-protein, high-calorie portable foods
is a standard nursing intervention for mania.
5. A patient recently started on Fluoxetine (Prozac) reports experiencing a rapid heartbeat,
sweating, and muscle spasms. What should the nurse suspect?
A. Serotonin Syndrome
B. Normal side effects of SSRIs
C. Anticholinergic crisis
D. Hypertensive crisis
Answer: A
Rationale: Serotonin syndrome is a potentially fatal condition caused by excessive
serotonin levels, often occurring when starting or increasing doses of SSRIs. Symptoms
include tachycardia, diaphoresis, hyperreflexia, and mental status changes. The nurse must
discontinue the offending agent and provide supportive care to manage symptoms.
6. Which statement by a patient taking Phenelzine (Nardil) indicates a need for further
teaching?
A. I will check with my pharmacist before taking cold medicine.
B. I should avoid eating aged cheeses and smoked meats.
C. I can have a glass of red wine with dinner occasionally.
D. I need to monitor my blood pressure regularly.
Answer: C
, Rationale: Phenelzine is an MAOI, which requires a strict tyramine-free diet to prevent a
hypertensive crisis. Red wine, aged cheeses, and cured meats are high in tyramine and
must be avoided completely. Educating the patient on these dietary restrictions is vital for
their safety while on this medication.
7. A patient with schizophrenia states, ‘The FBI is monitoring my thoughts through the
television.’ How should the nurse respond?
A. It sounds like you are feeling frightened by these thoughts.
B. I believe you, tell me more about what they are doing.
C. The FBI does not have the technology to do that.
D. Why do you think the FBI is interested in you?
Answer: A
Rationale: The nurse should acknowledge the patient’s feelings without validating the
delusion itself. This approach uses empathy to build rapport while remaining grounded in
reality. Directly arguing with a delusion is counterproductive and can damage the
therapeutic relationship.
8. A nurse is caring for a patient with severe Generalized Anxiety Disorder. Which
intervention is most effective during an acute anxiety attack?
A. Leave the patient alone to allow them space to calm down.
B. Encourage the patient to discuss the root cause of their anxiety.
C. Instruct the patient to use slow, deep abdominal breathing.
D. Teach the patient about long-term coping mechanisms.
Answer: C
Rationale: During an acute attack, the patient’s focus is limited, making complex teaching
or deep discussion ineffective. Deep breathing helps physiological stabilization and
provides a simple task for the patient to focus on. Staying with the patient and providing a
calm, quiet environment is also essential for safety.
9. A patient with OCD is late for a group session because they spent two hours washing their
hands. What is the most appropriate nursing intervention?
A. Prohibit the patient from washing their hands before group.
B. Ignore the behavior so the patient does not feel embarrassed.
C. Inform the patient that their behavior is disruptive to others.
D. Allow the ritual initially but gradually limit the time allowed.
Answer: D
