NUR2459/NUR 2459 Exam 2 V2 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A client is diagnosed with Schizophrenia and is experiencing auditory hallucinations. Which
nursing intervention is most appropriate during an acute hallucination episode?
A. Tell the client that the voices are not real and they should ignore them.
B. Argue with the client about the validity of their sensory perception.
C. Leave the client alone to provide a quiet environment for recovery.
D. Ask the client, ‘What are the voices saying to you right now?’
Correct Answer: D
Expert Explanation: Asking what the voices are saying helps the nurse assess for
command hallucinations that could lead to self-harm or violence. It is important to
acknowledge the client’s experience without validating the hallucination as reality. This
assessment is a priority for ensuring the safety of the client and others in the milieu.
2. A patient taking Lithium Carbonate for Bipolar Disorder presents with blurred vision,
severe diarrhea, and tremors. What is the nurse’s priority action?
A. Administer the next scheduled dose of Lithium.
,B. Hold the medication and notify the healthcare provider.
C. Instruct the patient to increase their fluid intake immediately.
D. Encourage the patient to rest until the symptoms subside.
Correct Answer: B
Expert Explanation: Blurred vision, diarrhea, and tremors are classic signs of Lithium
toxicity, which is a medical emergency. The nurse must immediately stop the medication to
prevent further toxicity and potential permanent organ damage. Notification of the
provider is essential to obtain a serum lithium level and initiate treatment.
3. Which personality disorder is characterized by a pervasive pattern of grandiosity, a need
for admiration, and a lack of empathy?
A. Borderline Personality Disorder
B. Antisocial Personality Disorder
C. Narcissistic Personality Disorder
D. Histrionic Personality Disorder
Correct Answer: C
Expert Explanation: Narcissistic Personality Disorder involves a sense of self-importance
and a preoccupation with fantasies of success. Individuals with this disorder often believe
they are special and unique and require excessive admiration from others. They typically
lack empathy for the feelings or needs of those around them.
, 4. A client with Major Depressive Disorder is prescribed Phenelzine, an MAOI. Which food
item should the nurse instruct the client to avoid?
A. Fresh apples and oranges
B. Aged cheddar cheese and red wine
C. Grilled chicken and white rice
D. Whole grain bread and butter
Correct Answer: B
Expert Explanation: MAOIs like Phenelzine require a low-tyramine diet to prevent a
hypertensive crisis. Aged cheeses, red wine, and fermented meats are high in tyramine and
must be strictly avoided. The nurse must educate the patient on these dietary restrictions
to ensure their safety while on the medication.
5. A patient is experiencing a manic episode. Which snack would be the most appropriate to
provide the patient to maintain nutrition?
A. A bowl of hot chicken noodle soup
B. A steak that requires cutting with a knife
C. A large salad with vinaigrette
D. A turkey and cheese wrap (finger food)
Correct Answer: D
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A client is diagnosed with Schizophrenia and is experiencing auditory hallucinations. Which
nursing intervention is most appropriate during an acute hallucination episode?
A. Tell the client that the voices are not real and they should ignore them.
B. Argue with the client about the validity of their sensory perception.
C. Leave the client alone to provide a quiet environment for recovery.
D. Ask the client, ‘What are the voices saying to you right now?’
Correct Answer: D
Expert Explanation: Asking what the voices are saying helps the nurse assess for
command hallucinations that could lead to self-harm or violence. It is important to
acknowledge the client’s experience without validating the hallucination as reality. This
assessment is a priority for ensuring the safety of the client and others in the milieu.
2. A patient taking Lithium Carbonate for Bipolar Disorder presents with blurred vision,
severe diarrhea, and tremors. What is the nurse’s priority action?
A. Administer the next scheduled dose of Lithium.
,B. Hold the medication and notify the healthcare provider.
C. Instruct the patient to increase their fluid intake immediately.
D. Encourage the patient to rest until the symptoms subside.
Correct Answer: B
Expert Explanation: Blurred vision, diarrhea, and tremors are classic signs of Lithium
toxicity, which is a medical emergency. The nurse must immediately stop the medication to
prevent further toxicity and potential permanent organ damage. Notification of the
provider is essential to obtain a serum lithium level and initiate treatment.
3. Which personality disorder is characterized by a pervasive pattern of grandiosity, a need
for admiration, and a lack of empathy?
A. Borderline Personality Disorder
B. Antisocial Personality Disorder
C. Narcissistic Personality Disorder
D. Histrionic Personality Disorder
Correct Answer: C
Expert Explanation: Narcissistic Personality Disorder involves a sense of self-importance
and a preoccupation with fantasies of success. Individuals with this disorder often believe
they are special and unique and require excessive admiration from others. They typically
lack empathy for the feelings or needs of those around them.
, 4. A client with Major Depressive Disorder is prescribed Phenelzine, an MAOI. Which food
item should the nurse instruct the client to avoid?
A. Fresh apples and oranges
B. Aged cheddar cheese and red wine
C. Grilled chicken and white rice
D. Whole grain bread and butter
Correct Answer: B
Expert Explanation: MAOIs like Phenelzine require a low-tyramine diet to prevent a
hypertensive crisis. Aged cheeses, red wine, and fermented meats are high in tyramine and
must be strictly avoided. The nurse must educate the patient on these dietary restrictions
to ensure their safety while on the medication.
5. A patient is experiencing a manic episode. Which snack would be the most appropriate to
provide the patient to maintain nutrition?
A. A bowl of hot chicken noodle soup
B. A steak that requires cutting with a knife
C. A large salad with vinaigrette
D. A turkey and cheese wrap (finger food)
Correct Answer: D
