NUR2459/NUR 2459 Final Exam V1
| Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A patient with severe anxiety is pacing the hallway and breathing rapidly. Which nursing
intervention is most appropriate?
A. Stay with the patient and use short, simple sentences.
B. Leave the patient alone to allow them space to calm down.
C. Provide a detailed explanation of anxiety management techniques.
D. Encourage the patient to join a group therapy session immediately.
Correct Answer: A
Expert Explanation: During severe anxiety, the patient’s perceptual field is significantly
narrowed and they cannot process complex information. Staying with the patient provides
a sense of safety and security. Short, simple sentences are necessary because the patient’s
ability to focus is limited at this level of anxiety.
2. A client is admitted for lithium toxicity. Which laboratory value should the nurse expect to
see?
A. 0.8 mEq/L
,B. 1.2 mEq/L
C. 2.1 mEq/L
D. 0.4 mEq/L
Correct Answer: C
Expert Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and levels
above 1.5 mEq/L are considered toxic. A level of 2.1 mEq/L indicates significant toxicity
that requires immediate medical intervention. The nurse must monitor for symptoms such
as coarse tremors, vomiting, and confusion at this level.
3. Which side effect of first-generation antipsychotics is considered a medical emergency?
A. Dry mouth
B. Mild photosensitivity
C. Weight gain
D. Neuroleptic Malignant Syndrome (NMS)
Correct Answer: D
Expert Explanation: Neuroleptic Malignant Syndrome is a rare but life-threatening
reaction to antipsychotic medications. It is characterized by high fever, muscle rigidity, and
autonomic instability. Immediate discontinuation of the drug and supportive care in an
intensive care unit are required to prevent death.
, 4. A nurse is caring for a patient who is experiencing auditory hallucinations. What is the
most therapeutic response?
A. “The voices are not real; you should try to ignore them.”
B. “Why do you think the voices are talking to you right now?”
C. “I don’t hear the voices, but I understand they are real to you.”
D. “What are the voices telling you to do?”
Correct Answer: C
Expert Explanation: Presenting reality while acknowledging the patient’s experience is
the standard of care for hallucinations. The nurse should not validate the hallucination as
real but should validate the patient’s feelings. This approach helps build trust without
reinforcing the psychotic symptoms.
5. A patient is prescribed Phenelzine (Nardil). Which food item should the nurse instruct the
patient to avoid?
A. Fresh apples
B. Grilled chicken
C. Aged cheddar cheese
D. Steamed broccoli
Correct Answer: C
| Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A patient with severe anxiety is pacing the hallway and breathing rapidly. Which nursing
intervention is most appropriate?
A. Stay with the patient and use short, simple sentences.
B. Leave the patient alone to allow them space to calm down.
C. Provide a detailed explanation of anxiety management techniques.
D. Encourage the patient to join a group therapy session immediately.
Correct Answer: A
Expert Explanation: During severe anxiety, the patient’s perceptual field is significantly
narrowed and they cannot process complex information. Staying with the patient provides
a sense of safety and security. Short, simple sentences are necessary because the patient’s
ability to focus is limited at this level of anxiety.
2. A client is admitted for lithium toxicity. Which laboratory value should the nurse expect to
see?
A. 0.8 mEq/L
,B. 1.2 mEq/L
C. 2.1 mEq/L
D. 0.4 mEq/L
Correct Answer: C
Expert Explanation: The therapeutic range for lithium is 0.6 to 1.2 mEq/L, and levels
above 1.5 mEq/L are considered toxic. A level of 2.1 mEq/L indicates significant toxicity
that requires immediate medical intervention. The nurse must monitor for symptoms such
as coarse tremors, vomiting, and confusion at this level.
3. Which side effect of first-generation antipsychotics is considered a medical emergency?
A. Dry mouth
B. Mild photosensitivity
C. Weight gain
D. Neuroleptic Malignant Syndrome (NMS)
Correct Answer: D
Expert Explanation: Neuroleptic Malignant Syndrome is a rare but life-threatening
reaction to antipsychotic medications. It is characterized by high fever, muscle rigidity, and
autonomic instability. Immediate discontinuation of the drug and supportive care in an
intensive care unit are required to prevent death.
, 4. A nurse is caring for a patient who is experiencing auditory hallucinations. What is the
most therapeutic response?
A. “The voices are not real; you should try to ignore them.”
B. “Why do you think the voices are talking to you right now?”
C. “I don’t hear the voices, but I understand they are real to you.”
D. “What are the voices telling you to do?”
Correct Answer: C
Expert Explanation: Presenting reality while acknowledging the patient’s experience is
the standard of care for hallucinations. The nurse should not validate the hallucination as
real but should validate the patient’s feelings. This approach helps build trust without
reinforcing the psychotic symptoms.
5. A patient is prescribed Phenelzine (Nardil). Which food item should the nurse instruct the
patient to avoid?
A. Fresh apples
B. Grilled chicken
C. Aged cheddar cheese
D. Steamed broccoli
Correct Answer: C
