NUR2459/NUR 2459 Final Exam V2
| Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client for suicidal ideation. Which question is the priority for the
nurse to ask?
A. Do you have a plan to harm yourself?
B. How long have you felt this way?
C. Why do you want to end your life?
D. Do you have a support system at home?
Correct Answer: A
Expert Explanation: The nurse must immediately determine if the client has a specific
plan and the means to carry it out. Assessing the lethality of the plan is the highest priority
for safety. This information guides the level of observation and precautions necessary for
the client.
2. A client with bipolar disorder is in a manic phase. Which meal is most appropriate for this
client?
A. Steak, baked potato, and salad
,B. Chicken nuggets, an apple, and a carton of milk
C. Spaghetti and meatballs with garlic bread
D. A bowl of vegetable soup and crackers
Correct Answer: B
Expert Explanation: Clients in a manic state are hyperactive and often unable to sit down
for a meal. Providing finger foods allows the client to eat while moving and maintain
nutritional intake. High-protein and high-calorie options are essential to meet the
increased metabolic demands of mania.
3. A nurse is caring for a client starting clozapine. Which laboratory result should the nurse
monitor most closely?
A. Serum creatinine
B. White blood cell count
C. Liver function tests
D. Blood urea nitrogen
Correct Answer: B
Expert Explanation: Clozapine carries a significant risk of agranulocytosis, which is a
dangerous drop in white blood cell counts. Regular monitoring of the WBC and Absolute
Neutrophil Count (ANC) is mandatory for patients on this medication. Nurses must educate
patients to report signs of infection like fever or sore throat immediately.
, 4. A client is experiencing a panic attack. Which action should the nurse take first?
A. Teach the client relaxation techniques
B. Leave the client alone to provide privacy
C. Stay with the client and remain calm
D. Ask the client to explain what triggered the attack
Correct Answer: C
Expert Explanation: Staying with the client provides a sense of safety and reduces the fear
of being alone during the episode. Using a calm, low-pitched voice helps decrease the
client’s anxiety level. During a panic attack, the client cannot learn new skills or engage in
complex discussions.
5. Which assessment finding is a classic sign of lithium toxicity?
A. Coarse hand tremors
B. Increased appetite
C. Constipation
D. Hyperactivity
Correct Answer: A
Expert Explanation: Coarse tremors are a late sign of lithium toxicity and require
immediate medical attention. Other signs include severe diarrhea, blurred vision, and
| Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a client for suicidal ideation. Which question is the priority for the
nurse to ask?
A. Do you have a plan to harm yourself?
B. How long have you felt this way?
C. Why do you want to end your life?
D. Do you have a support system at home?
Correct Answer: A
Expert Explanation: The nurse must immediately determine if the client has a specific
plan and the means to carry it out. Assessing the lethality of the plan is the highest priority
for safety. This information guides the level of observation and precautions necessary for
the client.
2. A client with bipolar disorder is in a manic phase. Which meal is most appropriate for this
client?
A. Steak, baked potato, and salad
,B. Chicken nuggets, an apple, and a carton of milk
C. Spaghetti and meatballs with garlic bread
D. A bowl of vegetable soup and crackers
Correct Answer: B
Expert Explanation: Clients in a manic state are hyperactive and often unable to sit down
for a meal. Providing finger foods allows the client to eat while moving and maintain
nutritional intake. High-protein and high-calorie options are essential to meet the
increased metabolic demands of mania.
3. A nurse is caring for a client starting clozapine. Which laboratory result should the nurse
monitor most closely?
A. Serum creatinine
B. White blood cell count
C. Liver function tests
D. Blood urea nitrogen
Correct Answer: B
Expert Explanation: Clozapine carries a significant risk of agranulocytosis, which is a
dangerous drop in white blood cell counts. Regular monitoring of the WBC and Absolute
Neutrophil Count (ANC) is mandatory for patients on this medication. Nurses must educate
patients to report signs of infection like fever or sore throat immediately.
, 4. A client is experiencing a panic attack. Which action should the nurse take first?
A. Teach the client relaxation techniques
B. Leave the client alone to provide privacy
C. Stay with the client and remain calm
D. Ask the client to explain what triggered the attack
Correct Answer: C
Expert Explanation: Staying with the client provides a sense of safety and reduces the fear
of being alone during the episode. Using a calm, low-pitched voice helps decrease the
client’s anxiety level. During a panic attack, the client cannot learn new skills or engage in
complex discussions.
5. Which assessment finding is a classic sign of lithium toxicity?
A. Coarse hand tremors
B. Increased appetite
C. Constipation
D. Hyperactivity
Correct Answer: A
Expert Explanation: Coarse tremors are a late sign of lithium toxicity and require
immediate medical attention. Other signs include severe diarrhea, blurred vision, and
