NUR2459 Exam 4 Actual Exam Style V3 |
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with Anorexia Nervosa who is on a weight restoration
program. Which nursing intervention is the highest priority during mealtime?
A. Permit the client to choose any food items they desire from the cafeteria.
B. Engage the client in a detailed discussion about their body image while they eat.
C. Observe the client for one hour after meals to prevent purging.
D. Allow the client to eat in their room to provide a quiet environment.
Answer: C
Rationale: Supervision after meals is critical to ensure the client does not engage in
compensatory behaviors like self-induced vomiting. This intervention directly supports the
physiological goal of weight gain and stabilization. AI Analysis: Monitoring promotes safety
and adherence to the treatment plan in an acute setting. Consistent observation helps
break the cycle of secrecy often found in eating disorders. This mirrors the standard of care
for inpatient psychiatric nutrition management.
2. Which physical finding is most characteristic of a client who has been engaging in chronic
self-induced vomiting associated with Bulimia Nervosa?
A. Significant dental erosion and calluses on the knuckles.
,B. Fine, downy hair growth on the face and back known as lanugo.
C. Extremely low blood pressure and a heart rate below 40 bpm.
D. Development of a prominent ‘buffalo hump’ on the upper back.
Answer: A
Rationale: Dental erosion occurs due to repeated exposure to stomach acid during
vomiting, while knuckle calluses (Russell’s sign) result from using the hand to induce the
gag reflex. These physical indicators are key diagnostic clues for bulimia even if the
patient’s weight is normal. AI Analysis: Physical assessment is vital because patients often
hide these behaviors due to shame. Identifying these signs allows the nurse to initiate
appropriate medical and psychological interventions. The presence of Russell’s sign is a
classic exam indicator for purging-type behaviors.
3. A client with Alzheimer’s Disease is frequently found wandering the hallways at night and
appears disoriented. Which intervention should the nurse implement first?
A. Request a prescription for a sedative to help the client sleep through the night.
B. Apply bilateral wrist restraints to keep the client in bed safely.
C. Place the client’s mattress on the floor and ensure the area is well-lit.
D. Move the client to a room far away from the nurse’s station to reduce noise.
Answer: C
,Rationale: Placing the mattress on the floor reduces the risk of falls if the client attempts to
get out of bed while disoriented. Proper lighting helps reduce illusions and fear that can
exacerbate nighttime confusion (sundowning). AI Analysis: Safety is the primary concern
for patients with neurocognitive disorders who wander. Non-pharmacological
interventions should always be attempted before chemical or physical restraints. This
approach respects the patient’s dignity while mitigating the high risk of injury from falls.
4. A nurse is assessing an elderly client who was admitted for a urinary tract infection and is
now experiencing acute confusion and visual hallucinations. Which condition is the client
likely experiencing?
A. Late-stage Alzheimer’s Disease
B. Delirium
C. Vascular Dementia
D. Schizophrenia
Answer: B
Rationale: Delirium is characterized by an acute onset, fluctuating levels of consciousness,
and is often caused by an underlying medical condition like an infection. Unlike dementia,
delirium is usually reversible once the primary cause is treated. AI Analysis: Rapid
identification of delirium is a nursing priority to prevent further cognitive decline or injury.
This scenario highlights the importance of recognizing the physiological triggers for
psychiatric symptoms in the elderly. The sudden change in baseline cognition is the
hallmark of this diagnosis.
, 5. A child is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and is prescribed
Methylphenidate. What should the nurse include in the caregiver’s teaching?
A. Administer the medication right before bedtime to improve sleep quality.
B. Monitor the child’s weight and height regularly due to potential growth suppression.
C. Expect the child to gain weight rapidly while taking this stimulant.
D. Avoid giving the child any protein while they are on this medication.
Answer: B
Rationale: Stimulant medications like methylphenidate can cause appetite suppression,
which may lead to weight loss and slowed growth in children. It is essential for parents to
track these metrics and report significant changes to the provider. AI Analysis: Managing
side effects is a core component of outpatient psychiatric care for pediatric patients.
Education regarding the timing of doses (avoiding evening doses) is also crucial to prevent
insomnia. This question tests the nurse’s knowledge of stimulant pharmacology and
developmental safety.
6. Which behavior is most characteristic of a child diagnosed with Conduct Disorder?
A. Having difficulty focusing on schoolwork and losing personal items.
B. Repeating certain words or phrases and avoiding eye contact.
C. Engaging in physical cruelty to animals and violating the basic rights of others.
D. Feeling extreme anxiety when separated from a parent or caregiver.
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with Anorexia Nervosa who is on a weight restoration
program. Which nursing intervention is the highest priority during mealtime?
A. Permit the client to choose any food items they desire from the cafeteria.
B. Engage the client in a detailed discussion about their body image while they eat.
C. Observe the client for one hour after meals to prevent purging.
D. Allow the client to eat in their room to provide a quiet environment.
Answer: C
Rationale: Supervision after meals is critical to ensure the client does not engage in
compensatory behaviors like self-induced vomiting. This intervention directly supports the
physiological goal of weight gain and stabilization. AI Analysis: Monitoring promotes safety
and adherence to the treatment plan in an acute setting. Consistent observation helps
break the cycle of secrecy often found in eating disorders. This mirrors the standard of care
for inpatient psychiatric nutrition management.
2. Which physical finding is most characteristic of a client who has been engaging in chronic
self-induced vomiting associated with Bulimia Nervosa?
A. Significant dental erosion and calluses on the knuckles.
,B. Fine, downy hair growth on the face and back known as lanugo.
C. Extremely low blood pressure and a heart rate below 40 bpm.
D. Development of a prominent ‘buffalo hump’ on the upper back.
Answer: A
Rationale: Dental erosion occurs due to repeated exposure to stomach acid during
vomiting, while knuckle calluses (Russell’s sign) result from using the hand to induce the
gag reflex. These physical indicators are key diagnostic clues for bulimia even if the
patient’s weight is normal. AI Analysis: Physical assessment is vital because patients often
hide these behaviors due to shame. Identifying these signs allows the nurse to initiate
appropriate medical and psychological interventions. The presence of Russell’s sign is a
classic exam indicator for purging-type behaviors.
3. A client with Alzheimer’s Disease is frequently found wandering the hallways at night and
appears disoriented. Which intervention should the nurse implement first?
A. Request a prescription for a sedative to help the client sleep through the night.
B. Apply bilateral wrist restraints to keep the client in bed safely.
C. Place the client’s mattress on the floor and ensure the area is well-lit.
D. Move the client to a room far away from the nurse’s station to reduce noise.
Answer: C
,Rationale: Placing the mattress on the floor reduces the risk of falls if the client attempts to
get out of bed while disoriented. Proper lighting helps reduce illusions and fear that can
exacerbate nighttime confusion (sundowning). AI Analysis: Safety is the primary concern
for patients with neurocognitive disorders who wander. Non-pharmacological
interventions should always be attempted before chemical or physical restraints. This
approach respects the patient’s dignity while mitigating the high risk of injury from falls.
4. A nurse is assessing an elderly client who was admitted for a urinary tract infection and is
now experiencing acute confusion and visual hallucinations. Which condition is the client
likely experiencing?
A. Late-stage Alzheimer’s Disease
B. Delirium
C. Vascular Dementia
D. Schizophrenia
Answer: B
Rationale: Delirium is characterized by an acute onset, fluctuating levels of consciousness,
and is often caused by an underlying medical condition like an infection. Unlike dementia,
delirium is usually reversible once the primary cause is treated. AI Analysis: Rapid
identification of delirium is a nursing priority to prevent further cognitive decline or injury.
This scenario highlights the importance of recognizing the physiological triggers for
psychiatric symptoms in the elderly. The sudden change in baseline cognition is the
hallmark of this diagnosis.
, 5. A child is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and is prescribed
Methylphenidate. What should the nurse include in the caregiver’s teaching?
A. Administer the medication right before bedtime to improve sleep quality.
B. Monitor the child’s weight and height regularly due to potential growth suppression.
C. Expect the child to gain weight rapidly while taking this stimulant.
D. Avoid giving the child any protein while they are on this medication.
Answer: B
Rationale: Stimulant medications like methylphenidate can cause appetite suppression,
which may lead to weight loss and slowed growth in children. It is essential for parents to
track these metrics and report significant changes to the provider. AI Analysis: Managing
side effects is a core component of outpatient psychiatric care for pediatric patients.
Education regarding the timing of doses (avoiding evening doses) is also crucial to prevent
insomnia. This question tests the nurse’s knowledge of stimulant pharmacology and
developmental safety.
6. Which behavior is most characteristic of a child diagnosed with Conduct Disorder?
A. Having difficulty focusing on schoolwork and losing personal items.
B. Repeating certain words or phrases and avoiding eye contact.
C. Engaging in physical cruelty to animals and violating the basic rights of others.
D. Feeling extreme anxiety when separated from a parent or caregiver.
