NUR 426 Exam 2 With Actual
Questions & Verified Answers ,Plus
Explained Rationales/Expert Verified
For Guaranteed Pass 2026/Latest
Update/Instant Download Pdf
1. A patient with schizophrenia is experiencing auditory
hallucinations and says, "The voices tell me to hurt myself."
What is the nurse's priority action?
a. Encourage the patient to ignore the voices
b. Assess the patient's suicide risk
c. Tell the patient the voices are not real
d. Document the statement and continue monitoring
b. Assess the patient's suicide risk
Rationale: The priority is always safety. Auditory hallucinations
commanding self-harm indicate a high risk for suicide, requiring
immediate assessment and intervention.
2. A patient with major depressive disorder reports insomnia and
loss of appetite. Which neurotransmitter imbalance is most
likely involved?
a. Dopamine
b. Acetylcholine
c. Serotonin and norepinephrine
d. Gamma-aminobutyric acid (GABA)
,c. Serotonin and norepinephrine
Rationale: Depression is commonly associated with decreased levels
of serotonin and norepinephrine, which regulate mood, sleep, and
appetite.
3. A patient taking lithium for bipolar disorder presents with
diarrhea, vomiting, and coarse tremors. What should the nurse
do first?
a. Encourage fluid intake
b. Hold the next lithium dose and notify the provider
c. Administer an antiemetic
d. Check the patient's blood pressure
b. Hold the next lithium dose and notify the provider
Rationale: These are signs of lithium toxicity. The priority is to
prevent further toxicity by holding the medication and notifying the
provider.
4. A patient with borderline personality disorder frequently
threatens self-harm when frustrated. Which is the most
therapeutic nursing approach?
a. Avoid confrontation
b. Set consistent limits and maintain boundaries
c. Respond to threats with reassurance only
d. Ignore manipulative behavior
b. Set consistent limits and maintain boundaries
Rationale: Consistent boundaries help patients understand limits
and reduce manipulative behaviors while maintaining safety.
5. A patient with generalized anxiety disorder asks for PRN
lorazepam every day. What is the nurse's best response?
a. "You can take it as often as you want."
b. "Let's discuss non-pharmacologic ways to manage anxiety
, first."
c. "I will give it to you now and every day after."
d. "You are not allowed to take medications for anxiety."
b. "Let's discuss non-pharmacologic ways to manage anxiety first."
Rationale: Benzodiazepines are habit-forming. Non-pharmacologic
interventions like cognitive-behavioral therapy and relaxation
techniques are first-line for daily management.
6. A patient with PTSD experiences flashbacks in the hospital.
What is the priority nursing intervention?
a. Encourage the patient to talk about the trauma immediately
b. Provide a safe and calm environment
c. Administer antipsychotic medication
d. Avoid discussing the trauma
b. Provide a safe and calm environment
Rationale: Safety and stabilization are the first priorities before
addressing traumatic memories or initiating therapy.
7. Which of the following is a common side effect of SSRIs?
a. Hypertension
b. Sexual dysfunction
c. Bradycardia
d. Hypoglycemia
b. Sexual dysfunction
Rationale: SSRIs often cause sexual side effects, including decreased
libido, delayed ejaculation, and anorgasmia.
8. A patient with schizophrenia is prescribed risperidone. Which
side effect should the nurse monitor for?
a. Weight loss
b. Extrapyramidal symptoms (EPS)
, c. Hypoglycemia
d. Insomnia
b. Extrapyramidal symptoms (EPS)
Rationale: Risperidone, an atypical antipsychotic, can cause EPS
including tremors, rigidity, and dystonia, particularly at higher
doses.
9. A patient taking MAOIs should avoid which food?
a. Yogurt
b. Spinach
c. Aged cheese
d. Chicken
c. Aged cheese
Rationale: MAOIs can cause hypertensive crisis when taken with
tyramine-rich foods such as aged cheese, cured meats, and
fermented products.
10. A nurse teaches a patient about cognitive-behavioral
therapy (CBT). Which statement indicates understanding?
a. "CBT changes brain chemistry directly."
b. "CBT helps me identify and change negative thought
patterns."
c. "CBT only focuses on past trauma."
d. "CBT requires hospitalization."
b. "CBT helps me identify and change negative thought patterns."
Rationale: CBT is a structured therapy that helps patients recognize
distorted thinking and develop healthier coping strategies.
11. A patient with mania is pacing and talking loudly. What is
the best nursing intervention?
a. Encourage group participation
Questions & Verified Answers ,Plus
Explained Rationales/Expert Verified
For Guaranteed Pass 2026/Latest
Update/Instant Download Pdf
1. A patient with schizophrenia is experiencing auditory
hallucinations and says, "The voices tell me to hurt myself."
What is the nurse's priority action?
a. Encourage the patient to ignore the voices
b. Assess the patient's suicide risk
c. Tell the patient the voices are not real
d. Document the statement and continue monitoring
b. Assess the patient's suicide risk
Rationale: The priority is always safety. Auditory hallucinations
commanding self-harm indicate a high risk for suicide, requiring
immediate assessment and intervention.
2. A patient with major depressive disorder reports insomnia and
loss of appetite. Which neurotransmitter imbalance is most
likely involved?
a. Dopamine
b. Acetylcholine
c. Serotonin and norepinephrine
d. Gamma-aminobutyric acid (GABA)
,c. Serotonin and norepinephrine
Rationale: Depression is commonly associated with decreased levels
of serotonin and norepinephrine, which regulate mood, sleep, and
appetite.
3. A patient taking lithium for bipolar disorder presents with
diarrhea, vomiting, and coarse tremors. What should the nurse
do first?
a. Encourage fluid intake
b. Hold the next lithium dose and notify the provider
c. Administer an antiemetic
d. Check the patient's blood pressure
b. Hold the next lithium dose and notify the provider
Rationale: These are signs of lithium toxicity. The priority is to
prevent further toxicity by holding the medication and notifying the
provider.
4. A patient with borderline personality disorder frequently
threatens self-harm when frustrated. Which is the most
therapeutic nursing approach?
a. Avoid confrontation
b. Set consistent limits and maintain boundaries
c. Respond to threats with reassurance only
d. Ignore manipulative behavior
b. Set consistent limits and maintain boundaries
Rationale: Consistent boundaries help patients understand limits
and reduce manipulative behaviors while maintaining safety.
5. A patient with generalized anxiety disorder asks for PRN
lorazepam every day. What is the nurse's best response?
a. "You can take it as often as you want."
b. "Let's discuss non-pharmacologic ways to manage anxiety
, first."
c. "I will give it to you now and every day after."
d. "You are not allowed to take medications for anxiety."
b. "Let's discuss non-pharmacologic ways to manage anxiety first."
Rationale: Benzodiazepines are habit-forming. Non-pharmacologic
interventions like cognitive-behavioral therapy and relaxation
techniques are first-line for daily management.
6. A patient with PTSD experiences flashbacks in the hospital.
What is the priority nursing intervention?
a. Encourage the patient to talk about the trauma immediately
b. Provide a safe and calm environment
c. Administer antipsychotic medication
d. Avoid discussing the trauma
b. Provide a safe and calm environment
Rationale: Safety and stabilization are the first priorities before
addressing traumatic memories or initiating therapy.
7. Which of the following is a common side effect of SSRIs?
a. Hypertension
b. Sexual dysfunction
c. Bradycardia
d. Hypoglycemia
b. Sexual dysfunction
Rationale: SSRIs often cause sexual side effects, including decreased
libido, delayed ejaculation, and anorgasmia.
8. A patient with schizophrenia is prescribed risperidone. Which
side effect should the nurse monitor for?
a. Weight loss
b. Extrapyramidal symptoms (EPS)
, c. Hypoglycemia
d. Insomnia
b. Extrapyramidal symptoms (EPS)
Rationale: Risperidone, an atypical antipsychotic, can cause EPS
including tremors, rigidity, and dystonia, particularly at higher
doses.
9. A patient taking MAOIs should avoid which food?
a. Yogurt
b. Spinach
c. Aged cheese
d. Chicken
c. Aged cheese
Rationale: MAOIs can cause hypertensive crisis when taken with
tyramine-rich foods such as aged cheese, cured meats, and
fermented products.
10. A nurse teaches a patient about cognitive-behavioral
therapy (CBT). Which statement indicates understanding?
a. "CBT changes brain chemistry directly."
b. "CBT helps me identify and change negative thought
patterns."
c. "CBT only focuses on past trauma."
d. "CBT requires hospitalization."
b. "CBT helps me identify and change negative thought patterns."
Rationale: CBT is a structured therapy that helps patients recognize
distorted thinking and develop healthier coping strategies.
11. A patient with mania is pacing and talking loudly. What is
the best nursing intervention?
a. Encourage group participation
