NUR2459 Final Exam V3 | NUR 2459
Mental and Behavioral Health Nursing
Exam Q&A | Rasmussen University
1. A nurse is performing a mental status examination (MSE) on a client. Which observation
specifically describes the client’s ‘affect’?
A. The client states, ‘I feel very hopeless and sad today.’
B. The client is oriented to person, place, and time.
C. The client demonstrates the ability to remember three words after five minutes.
D. The client shows no facial expression when discussing a recent loss.
Answer: D
Rationale: Affect refers to the outward, observable expression of a person’s internal
emotional state. In this scenario, a lack of facial expression is a clinical observation of a flat
affect. Mood, by contrast, is the subjective emotion reported by the client themselves.
2. A patient taking Lithium Carbonate for Bipolar Disorder reports blurred vision and a severe
headache. What is the priority nursing action?
A. Administer the next scheduled dose of Lithium.
B. Hold the medication and request a serum lithium level.
C. Encourage the patient to increase their sodium intake immediately.
,D. Advise the patient to lie down in a dark room until the headache passes.
Answer: B
Rationale: Blurred vision and severe headaches are potential signs of lithium toxicity,
which can be life-threatening. The nurse must hold the medication to prevent further
accumulation in the bloodstream. Obtaining a serum level is the definitive way to assess for
toxic concentrations above 1.5 mEq/L.
3. Which dietary choice by a client taking a Monoamine Oxidase Inhibitor (MAOI) indicates a
need for further teaching?
A. Fresh grilled chicken with steamed broccoli.
B. A bowl of fresh strawberries and yogurt.
C. Pepperoni pizza with extra aged cheddar cheese.
D. Baked potato with butter and chives.
Answer: C
Rationale: MAOIs interact with tyramine-rich foods, which can lead to a hypertensive
crisis. Pepperoni and aged cheeses are high in tyramine and must be avoided by patients on
these medications. Educating the patient on a low-tyramine diet is a critical safety
intervention in psychiatric nursing.
4. A client with Schizophrenia is experiencing auditory hallucinations and says, ‘The voices are
telling me to hurt my roommate.’ What is the nurse’s priority?
A. Place the client in a seclusion room immediately.
, B. Initiate one-to-one observation to ensure safety.
C. Tell the client that the voices are not real.
D. Administer a PRN dose of an anti-anxiety medication.
Answer: B
Rationale: Command hallucinations that involve harm to others represent an immediate
safety risk. One-to-one observation is necessary to monitor the client’s actions and prevent
violence. While medication may be used later, ensuring direct supervision is the most
immediate priority for safety.
5. Which physical finding is most characteristic of a client suffering from Bulimia Nervosa who
frequently induces vomiting?
A. Dental enamel erosion and parotid gland swelling.
B. Severe bradycardia and hypotension.
C. Lanugo on the back and arms.
D. Extreme emaciation with a BMI below 15.
Answer: A
Rationale: Frequent vomiting exposes the teeth to stomach acid, leading to the erosion of
dental enamel. The repeated stimulation of the salivary glands often causes noticeable
parotid gland swelling, known as ‘chipmunk cheeks.’ Lanugo and extreme emaciation are
more commonly associated with Anorexia Nervosa.
Mental and Behavioral Health Nursing
Exam Q&A | Rasmussen University
1. A nurse is performing a mental status examination (MSE) on a client. Which observation
specifically describes the client’s ‘affect’?
A. The client states, ‘I feel very hopeless and sad today.’
B. The client is oriented to person, place, and time.
C. The client demonstrates the ability to remember three words after five minutes.
D. The client shows no facial expression when discussing a recent loss.
Answer: D
Rationale: Affect refers to the outward, observable expression of a person’s internal
emotional state. In this scenario, a lack of facial expression is a clinical observation of a flat
affect. Mood, by contrast, is the subjective emotion reported by the client themselves.
2. A patient taking Lithium Carbonate for Bipolar Disorder reports blurred vision and a severe
headache. What is the priority nursing action?
A. Administer the next scheduled dose of Lithium.
B. Hold the medication and request a serum lithium level.
C. Encourage the patient to increase their sodium intake immediately.
,D. Advise the patient to lie down in a dark room until the headache passes.
Answer: B
Rationale: Blurred vision and severe headaches are potential signs of lithium toxicity,
which can be life-threatening. The nurse must hold the medication to prevent further
accumulation in the bloodstream. Obtaining a serum level is the definitive way to assess for
toxic concentrations above 1.5 mEq/L.
3. Which dietary choice by a client taking a Monoamine Oxidase Inhibitor (MAOI) indicates a
need for further teaching?
A. Fresh grilled chicken with steamed broccoli.
B. A bowl of fresh strawberries and yogurt.
C. Pepperoni pizza with extra aged cheddar cheese.
D. Baked potato with butter and chives.
Answer: C
Rationale: MAOIs interact with tyramine-rich foods, which can lead to a hypertensive
crisis. Pepperoni and aged cheeses are high in tyramine and must be avoided by patients on
these medications. Educating the patient on a low-tyramine diet is a critical safety
intervention in psychiatric nursing.
4. A client with Schizophrenia is experiencing auditory hallucinations and says, ‘The voices are
telling me to hurt my roommate.’ What is the nurse’s priority?
A. Place the client in a seclusion room immediately.
, B. Initiate one-to-one observation to ensure safety.
C. Tell the client that the voices are not real.
D. Administer a PRN dose of an anti-anxiety medication.
Answer: B
Rationale: Command hallucinations that involve harm to others represent an immediate
safety risk. One-to-one observation is necessary to monitor the client’s actions and prevent
violence. While medication may be used later, ensuring direct supervision is the most
immediate priority for safety.
5. Which physical finding is most characteristic of a client suffering from Bulimia Nervosa who
frequently induces vomiting?
A. Dental enamel erosion and parotid gland swelling.
B. Severe bradycardia and hypotension.
C. Lanugo on the back and arms.
D. Extreme emaciation with a BMI below 15.
Answer: A
Rationale: Frequent vomiting exposes the teeth to stomach acid, leading to the erosion of
dental enamel. The repeated stimulation of the salivary glands often causes noticeable
parotid gland swelling, known as ‘chipmunk cheeks.’ Lanugo and extreme emaciation are
more commonly associated with Anorexia Nervosa.
