NUR2459/NUR 2459 Final Exam V3
| Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is taking clozapine. Which of the following laboratory
findings should the nurse prioritize reporting to the provider?
A. White blood cell (WBC) count 2,500/mm3
B. Hemoglobin 13 g/dL
C. Platelets 200,000/mm3
D. Blood urea nitrogen (BUN) 15 mg/dL
Correct Answer: A
Expert Explanation: Clozapine can cause agranulocytosis, which is a life-threatening
decrease in white blood cells. A WBC count of 2,500/mm3 is significantly below the normal
range and indicates a high risk for infection. The nurse must monitor blood counts weekly
and report low values immediately to ensure patient safety.
2. A client diagnosed with bipolar disorder is in a manic phase. Which of the following snack
options is most appropriate for the nurse to provide?
A. A toasted ham and cheese sandwich
,B. A bowl of chicken noodle soup
C. A green salad with vinaigrette
D. A bowl of spaghetti with meatballs
Correct Answer: A
Expert Explanation: Clients in a manic phase often have high energy levels and cannot sit
still long enough to eat a full meal. Providing ‘finger foods’ that are high in calories and
protein allows the client to eat while moving. A sandwich is portable and nutrient-dense,
making it more practical than items requiring utensils like soup or salad.
3. A nurse is assessing a client for suicidal ideation. Which of the following questions is the
highest priority to ask?
A. How long have you felt this way?
B. Do you have a plan to harm yourself?
C. Do you have a support system at home?
D. Have you ever been hospitalized before?
Correct Answer: B
Expert Explanation: Assessing for a specific plan and the means to carry it out is the most
critical step in determining the level of suicide risk. If a client has a lethality plan, the nurse
must implement immediate safety precautions. Asking about the plan helps the healthcare
team prioritize interventions to prevent self-harm.
, 4. Which of the following findings is an early sign of lithium toxicity?
A. Seizures and hypotension
B. Fine hand tremors and nausea
C. Extreme polyuria and dehydration
D. Confusion and coarse tremors
Correct Answer: B
Expert Explanation: Early signs of lithium toxicity include gastrointestinal upset and mild
motor disturbances like fine tremors. These symptoms typically occur when blood levels
are near the upper limit of the therapeutic range. Monitoring for these signs allows for
early intervention and dosage adjustment before severe toxicity occurs.
5. A nurse is caring for a client with anorexia nervosa. Which of the following actions should
the nurse include in the plan of care?
A. Remain with the client for 60 minutes after meals
B. Allow the client to weigh themselves daily
C. Provide privacy during meal times
D. Encourage the client to exercise for 30 minutes daily
Correct Answer: A
Expert Explanation: Clients with anorexia may attempt to hide food or engage in purging
behaviors after eating. Staying with the client for an hour post-meal prevents these
| Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client who is taking clozapine. Which of the following laboratory
findings should the nurse prioritize reporting to the provider?
A. White blood cell (WBC) count 2,500/mm3
B. Hemoglobin 13 g/dL
C. Platelets 200,000/mm3
D. Blood urea nitrogen (BUN) 15 mg/dL
Correct Answer: A
Expert Explanation: Clozapine can cause agranulocytosis, which is a life-threatening
decrease in white blood cells. A WBC count of 2,500/mm3 is significantly below the normal
range and indicates a high risk for infection. The nurse must monitor blood counts weekly
and report low values immediately to ensure patient safety.
2. A client diagnosed with bipolar disorder is in a manic phase. Which of the following snack
options is most appropriate for the nurse to provide?
A. A toasted ham and cheese sandwich
,B. A bowl of chicken noodle soup
C. A green salad with vinaigrette
D. A bowl of spaghetti with meatballs
Correct Answer: A
Expert Explanation: Clients in a manic phase often have high energy levels and cannot sit
still long enough to eat a full meal. Providing ‘finger foods’ that are high in calories and
protein allows the client to eat while moving. A sandwich is portable and nutrient-dense,
making it more practical than items requiring utensils like soup or salad.
3. A nurse is assessing a client for suicidal ideation. Which of the following questions is the
highest priority to ask?
A. How long have you felt this way?
B. Do you have a plan to harm yourself?
C. Do you have a support system at home?
D. Have you ever been hospitalized before?
Correct Answer: B
Expert Explanation: Assessing for a specific plan and the means to carry it out is the most
critical step in determining the level of suicide risk. If a client has a lethality plan, the nurse
must implement immediate safety precautions. Asking about the plan helps the healthcare
team prioritize interventions to prevent self-harm.
, 4. Which of the following findings is an early sign of lithium toxicity?
A. Seizures and hypotension
B. Fine hand tremors and nausea
C. Extreme polyuria and dehydration
D. Confusion and coarse tremors
Correct Answer: B
Expert Explanation: Early signs of lithium toxicity include gastrointestinal upset and mild
motor disturbances like fine tremors. These symptoms typically occur when blood levels
are near the upper limit of the therapeutic range. Monitoring for these signs allows for
early intervention and dosage adjustment before severe toxicity occurs.
5. A nurse is caring for a client with anorexia nervosa. Which of the following actions should
the nurse include in the plan of care?
A. Remain with the client for 60 minutes after meals
B. Allow the client to weigh themselves daily
C. Provide privacy during meal times
D. Encourage the client to exercise for 30 minutes daily
Correct Answer: A
Expert Explanation: Clients with anorexia may attempt to hide food or engage in purging
behaviors after eating. Staying with the client for an hour post-meal prevents these
