NUR2459/NUR 2459 Exam 4 V3 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A patient with bipolar disorder is prescribed Lithium Carbonate. Which laboratory result
should the nurse prioritize reviewing to prevent toxicity?
A. Serum Sodium levels
B. Serum Potassium levels
C. Blood Urea Nitrogen (BUN)
D. White Blood Cell count
Correct Answer: A
Expert Explanation: Serum sodium levels are critical because lithium is a salt and its
excretion is inversely related to sodium levels. If sodium levels drop, the kidneys retain
lithium, potentially leading to toxic accumulation in the blood. The nurse must monitor for
dehydration or excessive sweating, which can trigger this imbalance.
2. A client is experiencing an acute manic episode. Which nursing intervention is most
appropriate to maintain a therapeutic milieu?
A. Encourage the client to join a crowded group therapy session.
,B. Strictly isolate the client in their room for 24 hours.
C. Allow the client to lead the community meeting to boost self-esteem.
D. Provide high-calorie finger foods for the client to eat while moving.
Correct Answer: D
Expert Explanation: Manic clients often have difficulty sitting still long enough to eat
adequate meals, so finger foods help maintain nutrition. Providing a high-calorie intake
supports the high physical energy output seen in mania. The nurse should also aim to
provide a low-stimulus environment rather than crowded group settings.
3. Which assessment finding is considered a ‘negative’ symptom of schizophrenia?
A. Flat affect and apathy
B. Delusions of grandeur
C. Auditory hallucinations
D. Disorganized speech
Correct Answer: A
Expert Explanation: Negative symptoms represent a loss or diminution of normal
function, such as flat affect, alogia, or avolition. Hallucinations and delusions are ‘positive’
symptoms because they are additions to normal perception. Understanding this distinction
is vital for determining the effectiveness of typical versus atypical antipsychotics.
, 4. A nurse is caring for a client with Borderline Personality Disorder. The client tells the day
shift nurse that the night shift nurse is ‘evil’ and ‘neglectful.’ What is the nurse observing?
A. Splitting
B. Projective identification
C. Reaction formation
D. Intellectualization
Correct Answer: A
Expert Explanation: Splitting is a primitive defense mechanism common in borderline
personality disorder where individuals perceive others as all good or all bad. This behavior
often leads to staff conflict and requires a consistent, unified team approach. The nurse
must remain neutral and refer the client back to the original caregiver when appropriate.
5. A client taking Clozapine for treatment-resistant schizophrenia reports a sore throat and
fever. What is the nurse’s priority action?
A. Withhold the medication and notify the provider for a CBC.
B. Suggest the client use warm salt-water gargles.
C. Administer an antipyretic as ordered.
D. Document the symptoms and monitor for 24 hours.
Correct Answer: A
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A patient with bipolar disorder is prescribed Lithium Carbonate. Which laboratory result
should the nurse prioritize reviewing to prevent toxicity?
A. Serum Sodium levels
B. Serum Potassium levels
C. Blood Urea Nitrogen (BUN)
D. White Blood Cell count
Correct Answer: A
Expert Explanation: Serum sodium levels are critical because lithium is a salt and its
excretion is inversely related to sodium levels. If sodium levels drop, the kidneys retain
lithium, potentially leading to toxic accumulation in the blood. The nurse must monitor for
dehydration or excessive sweating, which can trigger this imbalance.
2. A client is experiencing an acute manic episode. Which nursing intervention is most
appropriate to maintain a therapeutic milieu?
A. Encourage the client to join a crowded group therapy session.
,B. Strictly isolate the client in their room for 24 hours.
C. Allow the client to lead the community meeting to boost self-esteem.
D. Provide high-calorie finger foods for the client to eat while moving.
Correct Answer: D
Expert Explanation: Manic clients often have difficulty sitting still long enough to eat
adequate meals, so finger foods help maintain nutrition. Providing a high-calorie intake
supports the high physical energy output seen in mania. The nurse should also aim to
provide a low-stimulus environment rather than crowded group settings.
3. Which assessment finding is considered a ‘negative’ symptom of schizophrenia?
A. Flat affect and apathy
B. Delusions of grandeur
C. Auditory hallucinations
D. Disorganized speech
Correct Answer: A
Expert Explanation: Negative symptoms represent a loss or diminution of normal
function, such as flat affect, alogia, or avolition. Hallucinations and delusions are ‘positive’
symptoms because they are additions to normal perception. Understanding this distinction
is vital for determining the effectiveness of typical versus atypical antipsychotics.
, 4. A nurse is caring for a client with Borderline Personality Disorder. The client tells the day
shift nurse that the night shift nurse is ‘evil’ and ‘neglectful.’ What is the nurse observing?
A. Splitting
B. Projective identification
C. Reaction formation
D. Intellectualization
Correct Answer: A
Expert Explanation: Splitting is a primitive defense mechanism common in borderline
personality disorder where individuals perceive others as all good or all bad. This behavior
often leads to staff conflict and requires a consistent, unified team approach. The nurse
must remain neutral and refer the client back to the original caregiver when appropriate.
5. A client taking Clozapine for treatment-resistant schizophrenia reports a sore throat and
fever. What is the nurse’s priority action?
A. Withhold the medication and notify the provider for a CBC.
B. Suggest the client use warm salt-water gargles.
C. Administer an antipyretic as ordered.
D. Document the symptoms and monitor for 24 hours.
Correct Answer: A
