NUR2459/NUR 2459 Exam 3 V3 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing an acute manic
episode. What is the priority nursing intervention for this client?
A. Providing a high-calorie, finger-food diet to maintain nutrition
B. Encouraging the client to participate in group therapy sessions
C. Allowing the client to lead a discussion during the community meeting
D. Administering a dose of an antidepressant medication as ordered
Correct Answer: A
Expert Explanation: Clients in an acute manic state are often too hyperactive to sit down
for full meals, making finger foods a practical choice for maintaining caloric intake.
Nutrition and hydration are physiological priorities during mania because the client may
neglect these basic needs. This intervention helps prevent physical exhaustion and weight
loss associated with the manic phase.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
serum lithium level would the nurse recognize as being within the therapeutic range?
A. 0.9 mEq/L
,B. 0.2 mEq/L
C. 1.8 mEq/L
D. 2.5 mEq/L
Correct Answer: A
Expert Explanation: The standard therapeutic range for serum lithium levels in most
adult patients is 0.6 to 1.2 mEq/L. A level of 0.9 mEq/L falls squarely within this window,
ensuring effectiveness while minimizing toxicity risks. Levels below 0.6 mEq/L are
typically sub-therapeutic, while levels above 1.5 mEq/L indicate toxicity.
3. The nurse is assessing a client with Anorexia Nervosa. Which physical finding is most
characteristic of this disorder?
A. Hyperactive bowel sounds
B. Tachycardia and hypertension
C. Moist, oily skin and hair
D. Presence of lanugo on the back and arms
Correct Answer: D
Expert Explanation: Lanugo is the growth of fine, downy hair often found on the bodies of
individuals with severe Anorexia Nervosa as a physiological adaptation to maintain body
heat. Due to the lack of subcutaneous fat, the body attempts to insulate itself against the
,cold. This finding, along with bradycardia and hypotension, indicates a severe state of
malnutrition.
4. A client diagnosed with Borderline Personality Disorder frequently ‘splits’ the staff, praising
one nurse while demeaning another. How should the nursing staff respond to this behavior?
A. Allowing the client to choose which nurse they want to work with
B. Holding frequent staff meetings to maintain a consistent approach to the client’s care
C. Engaging in a debate with the client about the quality of the other nurse’s care
D. Ignoring the behavior entirely to avoid reinforcing it
Correct Answer: B
Expert Explanation: Consistency among the treatment team is vital when managing
splitting behaviors to prevent staff manipulation and division. By holding regular meetings,
the staff can ensure they are all adhering to the same care plan and boundaries. This
unified front helps the client learn that their attempts to polarize staff will not work.
5. A client is admitted to the hospital for alcohol withdrawal. Which symptom should the
nurse monitor for as the most serious complication of withdrawal?
A. Mild tremors
B. Insomnia
C. Delirium Tremens (DTs)
D. Diaphoresis
, Correct Answer: C
Expert Explanation: Delirium Tremens is a medical emergency that can occur 48 to 72
hours after the last drink and is characterized by severe autonomic instability,
hallucinations, and seizures. While tremors and sweating are common early signs of
withdrawal, DTs can be fatal if not treated promptly. Monitoring the client with
standardized tools like the CIWA-Ar is essential for early detection.
6. When assessing a client’s risk for suicide, which factor is the most significant indicator of
high lethality?
A. Expressing feelings of sadness and hopelessness
B. Having a specific plan with access to a highly lethal method, such as a firearm
C. A history of one previous suicide attempt five years ago
D. A family history of depression and anxiety
Correct Answer: B
Expert Explanation: The presence of a specific, high-lethality plan combined with
immediate access to the means is the most critical red flag in a suicide assessment.
Lethality refers to how quickly and effectively a method will result in death. Nurses must
prioritize safety and implement immediate one-to-one observation when such plans are
disclosed.
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client with Bipolar I Disorder who is experiencing an acute manic
episode. What is the priority nursing intervention for this client?
A. Providing a high-calorie, finger-food diet to maintain nutrition
B. Encouraging the client to participate in group therapy sessions
C. Allowing the client to lead a discussion during the community meeting
D. Administering a dose of an antidepressant medication as ordered
Correct Answer: A
Expert Explanation: Clients in an acute manic state are often too hyperactive to sit down
for full meals, making finger foods a practical choice for maintaining caloric intake.
Nutrition and hydration are physiological priorities during mania because the client may
neglect these basic needs. This intervention helps prevent physical exhaustion and weight
loss associated with the manic phase.
2. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
serum lithium level would the nurse recognize as being within the therapeutic range?
A. 0.9 mEq/L
,B. 0.2 mEq/L
C. 1.8 mEq/L
D. 2.5 mEq/L
Correct Answer: A
Expert Explanation: The standard therapeutic range for serum lithium levels in most
adult patients is 0.6 to 1.2 mEq/L. A level of 0.9 mEq/L falls squarely within this window,
ensuring effectiveness while minimizing toxicity risks. Levels below 0.6 mEq/L are
typically sub-therapeutic, while levels above 1.5 mEq/L indicate toxicity.
3. The nurse is assessing a client with Anorexia Nervosa. Which physical finding is most
characteristic of this disorder?
A. Hyperactive bowel sounds
B. Tachycardia and hypertension
C. Moist, oily skin and hair
D. Presence of lanugo on the back and arms
Correct Answer: D
Expert Explanation: Lanugo is the growth of fine, downy hair often found on the bodies of
individuals with severe Anorexia Nervosa as a physiological adaptation to maintain body
heat. Due to the lack of subcutaneous fat, the body attempts to insulate itself against the
,cold. This finding, along with bradycardia and hypotension, indicates a severe state of
malnutrition.
4. A client diagnosed with Borderline Personality Disorder frequently ‘splits’ the staff, praising
one nurse while demeaning another. How should the nursing staff respond to this behavior?
A. Allowing the client to choose which nurse they want to work with
B. Holding frequent staff meetings to maintain a consistent approach to the client’s care
C. Engaging in a debate with the client about the quality of the other nurse’s care
D. Ignoring the behavior entirely to avoid reinforcing it
Correct Answer: B
Expert Explanation: Consistency among the treatment team is vital when managing
splitting behaviors to prevent staff manipulation and division. By holding regular meetings,
the staff can ensure they are all adhering to the same care plan and boundaries. This
unified front helps the client learn that their attempts to polarize staff will not work.
5. A client is admitted to the hospital for alcohol withdrawal. Which symptom should the
nurse monitor for as the most serious complication of withdrawal?
A. Mild tremors
B. Insomnia
C. Delirium Tremens (DTs)
D. Diaphoresis
, Correct Answer: C
Expert Explanation: Delirium Tremens is a medical emergency that can occur 48 to 72
hours after the last drink and is characterized by severe autonomic instability,
hallucinations, and seizures. While tremors and sweating are common early signs of
withdrawal, DTs can be fatal if not treated promptly. Monitoring the client with
standardized tools like the CIWA-Ar is essential for early detection.
6. When assessing a client’s risk for suicide, which factor is the most significant indicator of
high lethality?
A. Expressing feelings of sadness and hopelessness
B. Having a specific plan with access to a highly lethal method, such as a firearm
C. A history of one previous suicide attempt five years ago
D. A family history of depression and anxiety
Correct Answer: B
Expert Explanation: The presence of a specific, high-lethality plan combined with
immediate access to the means is the most critical red flag in a suicide assessment.
Lethality refers to how quickly and effectively a method will result in death. Nurses must
prioritize safety and implement immediate one-to-one observation when such plans are
disclosed.
