NUR2459/NUR 2459 Exam 2 V3 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A patient is prescribed fluoxetine for major depressive disorder. Which of the following
symptoms should the nurse instruct the patient to report immediately as a potential sign of
serotonin syndrome?
A. Decreased libido and sexual dysfunction.
B. Muscle rigidity, fever, and tremors.
C. Dry mouth and occasional constipation.
D. Weight gain of 2 pounds in one week.
Correct Answer: B
Expert Explanation: Serotonin syndrome is a life-threatening condition caused by an
excess of serotonin in the body. Symptoms include mental status changes, autonomic
hyperactivity, and neuromuscular abnormalities such as muscle rigidity and tremors. The
nurse must educate the patient that these symptoms require urgent medical evaluation.
2. A nurse is caring for a client with Bipolar I Disorder who is in a manic phase. Which meal
choice is most appropriate for this client?
A. A bowl of chicken noodle soup with crackers.
,B. A cheeseburger, an apple, and a carton of milk.
C. Spaghetti with meatballs and a side salad.
D. Steak and mashed potatoes with gravy.
Correct Answer: B
Expert Explanation: Clients in a manic phase are often hyperactive and cannot sit still long
enough to eat a full meal. Providing ‘finger foods’ like a cheeseburger and an apple allows
the client to eat while moving. This strategy helps maintain nutritional intake and energy
levels during periods of high activity.
3. Which laboratory value is the priority for a nurse to monitor for a client taking clozapine
for schizophrenia?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium
C. Thyroid Stimulating Hormone (TSH)
D. White Blood Cell (WBC) count
Correct Answer: D
Expert Explanation: Clozapine carries a significant risk of agranulocytosis, which is a
dangerous drop in white blood cells. Mandatory blood monitoring of the WBC count and
Absolute Neutrophil Count (ANC) is required by law. If the count falls below a certain
threshold, the medication must be discontinued immediately to prevent severe infection.
, 4. A client tells the nurse, ‘Everyone here is out to get me and wants to poison my food.’
Which is the most therapeutic response by the nurse?
A. Why would anyone here want to hurt you?
B. I can see that you are feeling frightened, but I do not see anyone trying to poison you.
C. Don’t worry, the kitchen staff is very professional and followed by safety codes.
D. That is a very silly thing to say; no one is trying to kill you.
Correct Answer: B
Expert Explanation: This response acknowledges the client’s underlying feelings (fear)
without validating the delusion. It presents reality in a non-confrontational manner, which
is a key principle in therapeutic communication. Avoiding ‘why’ questions and direct
arguments helps maintain the therapeutic relationship.
5. A client is experiencing a panic-level of anxiety. Which nursing intervention is the most
appropriate at this time?
A. Teach the client deep breathing exercises for 15 minutes.
B. Leave the client alone in a quiet room to calm down.
C. Ask the client to explain the source of their anxiety in detail.
D. Stay with the client and use short, simple instructions.
Correct Answer: D
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A patient is prescribed fluoxetine for major depressive disorder. Which of the following
symptoms should the nurse instruct the patient to report immediately as a potential sign of
serotonin syndrome?
A. Decreased libido and sexual dysfunction.
B. Muscle rigidity, fever, and tremors.
C. Dry mouth and occasional constipation.
D. Weight gain of 2 pounds in one week.
Correct Answer: B
Expert Explanation: Serotonin syndrome is a life-threatening condition caused by an
excess of serotonin in the body. Symptoms include mental status changes, autonomic
hyperactivity, and neuromuscular abnormalities such as muscle rigidity and tremors. The
nurse must educate the patient that these symptoms require urgent medical evaluation.
2. A nurse is caring for a client with Bipolar I Disorder who is in a manic phase. Which meal
choice is most appropriate for this client?
A. A bowl of chicken noodle soup with crackers.
,B. A cheeseburger, an apple, and a carton of milk.
C. Spaghetti with meatballs and a side salad.
D. Steak and mashed potatoes with gravy.
Correct Answer: B
Expert Explanation: Clients in a manic phase are often hyperactive and cannot sit still long
enough to eat a full meal. Providing ‘finger foods’ like a cheeseburger and an apple allows
the client to eat while moving. This strategy helps maintain nutritional intake and energy
levels during periods of high activity.
3. Which laboratory value is the priority for a nurse to monitor for a client taking clozapine
for schizophrenia?
A. Blood Urea Nitrogen (BUN)
B. Serum Potassium
C. Thyroid Stimulating Hormone (TSH)
D. White Blood Cell (WBC) count
Correct Answer: D
Expert Explanation: Clozapine carries a significant risk of agranulocytosis, which is a
dangerous drop in white blood cells. Mandatory blood monitoring of the WBC count and
Absolute Neutrophil Count (ANC) is required by law. If the count falls below a certain
threshold, the medication must be discontinued immediately to prevent severe infection.
, 4. A client tells the nurse, ‘Everyone here is out to get me and wants to poison my food.’
Which is the most therapeutic response by the nurse?
A. Why would anyone here want to hurt you?
B. I can see that you are feeling frightened, but I do not see anyone trying to poison you.
C. Don’t worry, the kitchen staff is very professional and followed by safety codes.
D. That is a very silly thing to say; no one is trying to kill you.
Correct Answer: B
Expert Explanation: This response acknowledges the client’s underlying feelings (fear)
without validating the delusion. It presents reality in a non-confrontational manner, which
is a key principle in therapeutic communication. Avoiding ‘why’ questions and direct
arguments helps maintain the therapeutic relationship.
5. A client is experiencing a panic-level of anxiety. Which nursing intervention is the most
appropriate at this time?
A. Teach the client deep breathing exercises for 15 minutes.
B. Leave the client alone in a quiet room to calm down.
C. Ask the client to explain the source of their anxiety in detail.
D. Stay with the client and use short, simple instructions.
Correct Answer: D
