NUR2459 Exam 3 Actual Exam Style V1 |
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with Bipolar I disorder who is experiencing acute mania. Which
of the following nutritional interventions is most appropriate?
A. Provide a large, three-course meal in the dining hall.
B. Offer high-calorie finger foods that can be eaten while pacing.
C. Limit fluid intake to prevent water intoxication.
D. Require the client to sit at a table for at least 20 minutes.
Correct Answer: B
Expert Explanation: Clients in an acute manic state often have too much energy to sit
down for a traditional meal. Providing high-calorie finger foods allow the client to maintain
nutritional intake while remaining mobile. This intervention addresses the physical risk of
exhaustion and weight loss during a manic episode.
2. A client is prescribed Lithium Carbonate for the treatment of bipolar disorder. Which
laboratory value should the nurse report to the provider immediately?
A. Lithium level of 0.8 mEq/L.
B. Lithium level of 1.8 mEq/L.
C. Sodium level of 140 mEq/L.
,D. Potassium level of 4.0 mEq/L.
Correct Answer: B
Expert Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range of 0.6 to
1.2 mEq/L and indicates toxicity. Toxicity can lead to serious neurological and cardiac
complications if not addressed promptly. The nurse must hold the medication and notify
the healthcare provider immediately for further orders.
3. A client with Schizophrenia is hearing voices telling them that the food is poisoned. What is
the priority nursing action?
A. Tell the client that their fear is silly and unfounded.
B. Ask the client directly what the voices are saying.
C. Agree with the client and offer to taste the food first.
D. Ignore the behavior to avoid reinforcing the hallucination.
Correct Answer: B
Expert Explanation: The nurse should ask what the voices are saying to assess for
command hallucinations that might involve harm to self or others. Acknowledging the
client’s experience without validating the delusion helps build trust. Safety is always the
priority when dealing with active hallucinations in psychiatric patients.
4. Which personality disorder is characterized by a pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation?
A. Antisocial Personality Disorder
, B. Narcissistic Personality Disorder
C. Avoidant Personality Disorder
D. Borderline Personality Disorder
Correct Answer: C
Expert Explanation: Avoidant Personality Disorder involves extreme shyness and a fear of
rejection in social situations. Individuals with this disorder desperately want relationships
but are too afraid of being judged or shamed to seek them out. This differs from Schizoid
Personality Disorder, where the individual typically has no desire for social connection.
5. A nurse observes a client with Borderline Personality Disorder telling one nurse they are
‘the best’ and another nurse they are ‘evil.’ This behavior is known as:
A. Rationalization
B. Projection
C. Reaction Formation
D. Splitting
Correct Answer: D
Expert Explanation: Splitting is a common defense mechanism where individuals view
others as either entirely good or entirely bad with no middle ground. This behavior often
creates conflict and division among the nursing staff on a psychiatric unit. Nurses must
maintain consistent boundaries and communication to manage this behavior effectively.
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with Bipolar I disorder who is experiencing acute mania. Which
of the following nutritional interventions is most appropriate?
A. Provide a large, three-course meal in the dining hall.
B. Offer high-calorie finger foods that can be eaten while pacing.
C. Limit fluid intake to prevent water intoxication.
D. Require the client to sit at a table for at least 20 minutes.
Correct Answer: B
Expert Explanation: Clients in an acute manic state often have too much energy to sit
down for a traditional meal. Providing high-calorie finger foods allow the client to maintain
nutritional intake while remaining mobile. This intervention addresses the physical risk of
exhaustion and weight loss during a manic episode.
2. A client is prescribed Lithium Carbonate for the treatment of bipolar disorder. Which
laboratory value should the nurse report to the provider immediately?
A. Lithium level of 0.8 mEq/L.
B. Lithium level of 1.8 mEq/L.
C. Sodium level of 140 mEq/L.
,D. Potassium level of 4.0 mEq/L.
Correct Answer: B
Expert Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range of 0.6 to
1.2 mEq/L and indicates toxicity. Toxicity can lead to serious neurological and cardiac
complications if not addressed promptly. The nurse must hold the medication and notify
the healthcare provider immediately for further orders.
3. A client with Schizophrenia is hearing voices telling them that the food is poisoned. What is
the priority nursing action?
A. Tell the client that their fear is silly and unfounded.
B. Ask the client directly what the voices are saying.
C. Agree with the client and offer to taste the food first.
D. Ignore the behavior to avoid reinforcing the hallucination.
Correct Answer: B
Expert Explanation: The nurse should ask what the voices are saying to assess for
command hallucinations that might involve harm to self or others. Acknowledging the
client’s experience without validating the delusion helps build trust. Safety is always the
priority when dealing with active hallucinations in psychiatric patients.
4. Which personality disorder is characterized by a pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation?
A. Antisocial Personality Disorder
, B. Narcissistic Personality Disorder
C. Avoidant Personality Disorder
D. Borderline Personality Disorder
Correct Answer: C
Expert Explanation: Avoidant Personality Disorder involves extreme shyness and a fear of
rejection in social situations. Individuals with this disorder desperately want relationships
but are too afraid of being judged or shamed to seek them out. This differs from Schizoid
Personality Disorder, where the individual typically has no desire for social connection.
5. A nurse observes a client with Borderline Personality Disorder telling one nurse they are
‘the best’ and another nurse they are ‘evil.’ This behavior is known as:
A. Rationalization
B. Projection
C. Reaction Formation
D. Splitting
Correct Answer: D
Expert Explanation: Splitting is a common defense mechanism where individuals view
others as either entirely good or entirely bad with no middle ground. This behavior often
creates conflict and division among the nursing staff on a psychiatric unit. Nurses must
maintain consistent boundaries and communication to manage this behavior effectively.
