NUR2459 Final Exam Actual Exam Style V3
| NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client who is taking Lithium Carbonate for Bipolar Disorder. The
client’s lithium level is 2.1 mEq/L. Which action should the nurse take first?
A. Administer the next scheduled dose of lithium.
B. Initiate gastric lavage or hemodialysis as ordered.
C. Encourage the client to increase fluid intake.
D. Document the findings as a therapeutic level.
Correct Answer: B
Expert Explanation: A lithium level of 2.1 mEq/L indicates severe toxicity, as the
therapeutic range is 0.6 to 1.2 mEq/L. Levels above 2.0 often require immediate
intervention such as gastric lavage or hemodialysis to prevent permanent organ damage or
death. The nurse must prioritize emergency measures and notify the provider immediately.
2. A client is experiencing an acute manic episode and is hyperactive, frequently interrupting
others. Which of the following nursing interventions is the priority?
A. Provide structured, high-calorie finger foods.
B. Explain the rules of the unit in detail.
C. Place the client in a group therapy session.
,D. Encourage the client to participate in a basketball game.
Correct Answer: A
Expert Explanation: During an acute manic episode, clients are often too hyperactive to sit
for meals, leading to weight loss and exhaustion. High-calorie finger foods allow the client
to eat while on the move, addressing physiological needs for energy and nutrition.
Reducing stimuli and ensuring safety are also key components of care for mania.
3. A nurse is assessing a client for Serotonin Syndrome. Which of the following findings
should the nurse expect?
A. Hyporeflexia and bradycardia.
B. Constipation and urinary retention.
C. Muscle rigidity, fever, and diaphoresis.
D. Significant weight gain and increased appetite.
Correct Answer: C
Expert Explanation: Serotonin Syndrome is a life-threatening condition caused by excess
serotonin, characterized by mental status changes and autonomic hyperactivity. Clinical
manifestations include muscle rigidity, hyperreflexia, fever, and diaphoresis. Immediate
discontinuation of the offending agent and supportive care are the primary treatments.
4. Which statement by a client indicates an understanding of the teaching regarding
Monoamine Oxidase Inhibitors (MAOIs)?
A. I can eat aged cheese as long as I take it with food.
, B. I will avoid foods like avocados, pepperoni, and red wine.
C. I will switch to an SSRI immediately if this doesn’t work.
D. I can use over-the-counter cold medications for congestion.
Correct Answer: B
Expert Explanation: MAOIs interact with tyramine-rich foods to cause a hypertensive
crisis. Foods such as aged cheeses, cured meats, and certain alcohols must be strictly
avoided. Clients must also wait at least 14 days when switching between MAOIs and other
antidepressants like SSRIs to prevent serotonin syndrome.
5. A nurse is caring for a client with Schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. I don’t hear any voices; you are imagining things.
B. Try to ignore the voices and focus on your homework.
C. I hear the voices too; let’s talk to them together.
D. What are the voices telling you to do?
Correct Answer: D
Expert Explanation: Assessing the content of hallucinations is critical, especially to
determine if the client is hearing command hallucinations that could lead to self-harm or
violence. This approach acknowledges the client’s experience without validating the
| NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client who is taking Lithium Carbonate for Bipolar Disorder. The
client’s lithium level is 2.1 mEq/L. Which action should the nurse take first?
A. Administer the next scheduled dose of lithium.
B. Initiate gastric lavage or hemodialysis as ordered.
C. Encourage the client to increase fluid intake.
D. Document the findings as a therapeutic level.
Correct Answer: B
Expert Explanation: A lithium level of 2.1 mEq/L indicates severe toxicity, as the
therapeutic range is 0.6 to 1.2 mEq/L. Levels above 2.0 often require immediate
intervention such as gastric lavage or hemodialysis to prevent permanent organ damage or
death. The nurse must prioritize emergency measures and notify the provider immediately.
2. A client is experiencing an acute manic episode and is hyperactive, frequently interrupting
others. Which of the following nursing interventions is the priority?
A. Provide structured, high-calorie finger foods.
B. Explain the rules of the unit in detail.
C. Place the client in a group therapy session.
,D. Encourage the client to participate in a basketball game.
Correct Answer: A
Expert Explanation: During an acute manic episode, clients are often too hyperactive to sit
for meals, leading to weight loss and exhaustion. High-calorie finger foods allow the client
to eat while on the move, addressing physiological needs for energy and nutrition.
Reducing stimuli and ensuring safety are also key components of care for mania.
3. A nurse is assessing a client for Serotonin Syndrome. Which of the following findings
should the nurse expect?
A. Hyporeflexia and bradycardia.
B. Constipation and urinary retention.
C. Muscle rigidity, fever, and diaphoresis.
D. Significant weight gain and increased appetite.
Correct Answer: C
Expert Explanation: Serotonin Syndrome is a life-threatening condition caused by excess
serotonin, characterized by mental status changes and autonomic hyperactivity. Clinical
manifestations include muscle rigidity, hyperreflexia, fever, and diaphoresis. Immediate
discontinuation of the offending agent and supportive care are the primary treatments.
4. Which statement by a client indicates an understanding of the teaching regarding
Monoamine Oxidase Inhibitors (MAOIs)?
A. I can eat aged cheese as long as I take it with food.
, B. I will avoid foods like avocados, pepperoni, and red wine.
C. I will switch to an SSRI immediately if this doesn’t work.
D. I can use over-the-counter cold medications for congestion.
Correct Answer: B
Expert Explanation: MAOIs interact with tyramine-rich foods to cause a hypertensive
crisis. Foods such as aged cheeses, cured meats, and certain alcohols must be strictly
avoided. Clients must also wait at least 14 days when switching between MAOIs and other
antidepressants like SSRIs to prevent serotonin syndrome.
5. A nurse is caring for a client with Schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. I don’t hear any voices; you are imagining things.
B. Try to ignore the voices and focus on your homework.
C. I hear the voices too; let’s talk to them together.
D. What are the voices telling you to do?
Correct Answer: D
Expert Explanation: Assessing the content of hallucinations is critical, especially to
determine if the client is hearing command hallucinations that could lead to self-harm or
violence. This approach acknowledges the client’s experience without validating the
