NUR2459/NUR 2459 Final Exam V1 |
Mental and Behavioral Health Nursing
Q&A with Rationale | Rasmussen
University
1. A patient is admitted to the psychiatric unit after a suicide attempt. Which nursing
intervention is the highest priority?
A. Implementing one-on-one continuous observation for safety.
B. Administering prescribed antidepressant medications promptly.
C. Encouraging the patient to participate in group therapy sessions.
D. Assessing the patient’s history of previous mental health issues.
Answer: A
Rationale: The safety of the patient is the immediate priority following a suicide attempt to
prevent further self-harm. Continuous one-on-one observation ensures the nurse can
intervene immediately if the patient attempts to harm themselves again. While group
therapy and medications are important for long-term recovery, they do not address the
immediate crisis of safety.
2. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response is most therapeutic?
A. I don’t hear the voices, but I understand that they are real to you.
,B. Why do you think you are hearing voices right now?
C. The voices are not real, so you should try to ignore them.
D. What are the voices telling you to do?
Answer: A
Rationale: Validating the patient’s experience without agreeing with the hallucination
helps build trust and reality orientation. It acknowledges the patient’s distress while
maintaining a foundation in reality. Asking why can be perceived as accusatory, and telling
them the voices are not real is dismissive and non-therapeutic.
3. Which lab value is most important to monitor for a patient taking Clozapine?
A. White blood cell (WBC) count.
B. Serum potassium levels.
C. Blood urea nitrogen (BUN).
D. Aspartate aminotransferase (AST).
Answer: A
Rationale: Clozapine carries a high risk for agranulocytosis, which is a dangerous drop in
the white blood cell count. Regular monitoring of the absolute neutrophil count and WBC is
required by law to continue the medication. Patients must be taught to report any signs of
infection, such as fever or sore throat, immediately.
, 4. A client is diagnosed with Bipolar I Disorder and is in a manic phase. Which meal is most
appropriate for this patient?
A. A turkey wrap, an apple, and a carton of juice.
B. Chicken soup with crackers and a glass of milk.
C. Steak, baked potato, and a side salad.
D. Spaghetti with meatballs and a slice of garlic bread.
Answer: A
Rationale: Patients in a manic phase often have high energy levels and cannot sit still long
enough to eat a full meal. Providing ‘finger foods’ allows the patient to consume calories
while remaining mobile. This intervention helps prevent nutritional deficits and weight
loss during periods of extreme hyperactivity.
5. A patient is prescribed Lithium Carbonate for Bipolar Disorder. What is the therapeutic
blood level range?
A. 0.6 to 1.2 mEq/L.
B. 0.1 to 0.5 mEq/L.
C. 1.5 to 2.0 mEq/L.
D. 2.5 to 3.0 mEq/L.
Answer: A
Mental and Behavioral Health Nursing
Q&A with Rationale | Rasmussen
University
1. A patient is admitted to the psychiatric unit after a suicide attempt. Which nursing
intervention is the highest priority?
A. Implementing one-on-one continuous observation for safety.
B. Administering prescribed antidepressant medications promptly.
C. Encouraging the patient to participate in group therapy sessions.
D. Assessing the patient’s history of previous mental health issues.
Answer: A
Rationale: The safety of the patient is the immediate priority following a suicide attempt to
prevent further self-harm. Continuous one-on-one observation ensures the nurse can
intervene immediately if the patient attempts to harm themselves again. While group
therapy and medications are important for long-term recovery, they do not address the
immediate crisis of safety.
2. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response is most therapeutic?
A. I don’t hear the voices, but I understand that they are real to you.
,B. Why do you think you are hearing voices right now?
C. The voices are not real, so you should try to ignore them.
D. What are the voices telling you to do?
Answer: A
Rationale: Validating the patient’s experience without agreeing with the hallucination
helps build trust and reality orientation. It acknowledges the patient’s distress while
maintaining a foundation in reality. Asking why can be perceived as accusatory, and telling
them the voices are not real is dismissive and non-therapeutic.
3. Which lab value is most important to monitor for a patient taking Clozapine?
A. White blood cell (WBC) count.
B. Serum potassium levels.
C. Blood urea nitrogen (BUN).
D. Aspartate aminotransferase (AST).
Answer: A
Rationale: Clozapine carries a high risk for agranulocytosis, which is a dangerous drop in
the white blood cell count. Regular monitoring of the absolute neutrophil count and WBC is
required by law to continue the medication. Patients must be taught to report any signs of
infection, such as fever or sore throat, immediately.
, 4. A client is diagnosed with Bipolar I Disorder and is in a manic phase. Which meal is most
appropriate for this patient?
A. A turkey wrap, an apple, and a carton of juice.
B. Chicken soup with crackers and a glass of milk.
C. Steak, baked potato, and a side salad.
D. Spaghetti with meatballs and a slice of garlic bread.
Answer: A
Rationale: Patients in a manic phase often have high energy levels and cannot sit still long
enough to eat a full meal. Providing ‘finger foods’ allows the patient to consume calories
while remaining mobile. This intervention helps prevent nutritional deficits and weight
loss during periods of extreme hyperactivity.
5. A patient is prescribed Lithium Carbonate for Bipolar Disorder. What is the therapeutic
blood level range?
A. 0.6 to 1.2 mEq/L.
B. 0.1 to 0.5 mEq/L.
C. 1.5 to 2.0 mEq/L.
D. 2.5 to 3.0 mEq/L.
Answer: A
