NUR2459/NUR 2459 Exam 2 V1 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is taking lithium carbonate for bipolar disorder. The
client’s lithium level is 1.4 mEq/L. Which action should the nurse take?
A. Administer the next dose as scheduled.
B. Immediately notify the provider for toxicity.
C. Request a stat repeat lithium level.
D. Assess the client for signs of toxicity such as tremors or diarrhea.
Correct Answer: D
Expert Explanation: A lithium level of 1.4 mEq/L is at the high end of the therapeutic
range and bordering on toxicity. The nurse should first assess the client for symptoms such
as vomiting, diarrhea, or fine motor tremors. This assessment provides clinical context
before deciding to withhold medication or notify the provider.
2. A client with depression is prescribed Phenelzine (an MAOI). Which food choice indicates
the client needs further teaching?
A. A sandwich with aged cheddar cheese and salami.
,B. Grilled chicken breast with steamed broccoli.
C. Fresh green salad with oil and vinegar dressing.
D. Scrambled eggs with sliced tomatoes.
Correct Answer: A
Expert Explanation: Phenelzine is an MAOI that requires a low-tyramine diet to prevent
hypertensive crisis. Aged cheeses and cured meats like salami are high in tyramine and
must be avoided. Education should emphasize the risk of life-threatening blood pressure
spikes if these foods are consumed.
3. Which assessment finding should the nurse prioritize in a client with an eating disorder?
A. Body mass index of 17.5.
B. Heart rate of 48 beats per minute.
C. Amenorrhea for three consecutive months.
D. Presence of lanugo on the back.
Correct Answer: B
Expert Explanation: A heart rate of 48 beats per minute indicates severe bradycardia,
which can lead to cardiac arrest in patients with anorexia nervosa. While a low BMI and
lanugo are characteristic, cardiovascular stability is the physiological priority. The nurse
must monitor for electrolyte imbalances that contribute to these cardiac changes.
, 4. A nurse is caring for a client experiencing a panic attack. Which intervention is most
appropriate?
A. Explain the causes of panic attacks to the client.
B. Stay with the client and use short, simple sentences.
C. Encourage the client to practice deep breathing exercises.
D. Leave the client alone to reduce environmental stimuli.
Correct Answer: B
Expert Explanation: During a panic attack, the client’s ability to process information is
severely limited due to extreme anxiety. Staying with the client provides a sense of safety
and security during the crisis. Short, simple sentences are more easily understood when
the client is in a state of terror.
5. A client is admitted for alcohol withdrawal. Which medication should the nurse expect to
administer first to manage tremors and prevent seizures?
A. Disulfiram
B. Naltrexone
C. Lorazepam
D. Methadone
Correct Answer: C
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client who is taking lithium carbonate for bipolar disorder. The
client’s lithium level is 1.4 mEq/L. Which action should the nurse take?
A. Administer the next dose as scheduled.
B. Immediately notify the provider for toxicity.
C. Request a stat repeat lithium level.
D. Assess the client for signs of toxicity such as tremors or diarrhea.
Correct Answer: D
Expert Explanation: A lithium level of 1.4 mEq/L is at the high end of the therapeutic
range and bordering on toxicity. The nurse should first assess the client for symptoms such
as vomiting, diarrhea, or fine motor tremors. This assessment provides clinical context
before deciding to withhold medication or notify the provider.
2. A client with depression is prescribed Phenelzine (an MAOI). Which food choice indicates
the client needs further teaching?
A. A sandwich with aged cheddar cheese and salami.
,B. Grilled chicken breast with steamed broccoli.
C. Fresh green salad with oil and vinegar dressing.
D. Scrambled eggs with sliced tomatoes.
Correct Answer: A
Expert Explanation: Phenelzine is an MAOI that requires a low-tyramine diet to prevent
hypertensive crisis. Aged cheeses and cured meats like salami are high in tyramine and
must be avoided. Education should emphasize the risk of life-threatening blood pressure
spikes if these foods are consumed.
3. Which assessment finding should the nurse prioritize in a client with an eating disorder?
A. Body mass index of 17.5.
B. Heart rate of 48 beats per minute.
C. Amenorrhea for three consecutive months.
D. Presence of lanugo on the back.
Correct Answer: B
Expert Explanation: A heart rate of 48 beats per minute indicates severe bradycardia,
which can lead to cardiac arrest in patients with anorexia nervosa. While a low BMI and
lanugo are characteristic, cardiovascular stability is the physiological priority. The nurse
must monitor for electrolyte imbalances that contribute to these cardiac changes.
, 4. A nurse is caring for a client experiencing a panic attack. Which intervention is most
appropriate?
A. Explain the causes of panic attacks to the client.
B. Stay with the client and use short, simple sentences.
C. Encourage the client to practice deep breathing exercises.
D. Leave the client alone to reduce environmental stimuli.
Correct Answer: B
Expert Explanation: During a panic attack, the client’s ability to process information is
severely limited due to extreme anxiety. Staying with the client provides a sense of safety
and security during the crisis. Short, simple sentences are more easily understood when
the client is in a state of terror.
5. A client is admitted for alcohol withdrawal. Which medication should the nurse expect to
administer first to manage tremors and prevent seizures?
A. Disulfiram
B. Naltrexone
C. Lorazepam
D. Methadone
Correct Answer: C
