NSG 322/NSG322 Final Exam V2 |
Behavioral Health Nursing Q&A with
Rationale | Grand Canyon University
1. A nurse is caring for a client who is taking clozapine. Which of the following laboratory
findings should the nurse prioritize?
A. Sodium level of 138 mEq/L
B. WBC count of 2,500/mm3
C. Potassium level of 4.2 mEq/L
D. Blood glucose of 105 mg/dL
Correct Answer: B
Expert Explanation: Clozapine carries a significant risk for agranulocytosis, which is a
dangerous decrease in white blood cell counts. A WBC count of 2,500/mm3 is below the
normal range and indicates that the client is at high risk for infection. The nurse must
notify the provider immediately and monitor for signs of fever or sore throat.
2. A client is experiencing lithium toxicity with a blood level of 2.2 mEq/L. What is the priority
nursing intervention?
A. Administer the next scheduled dose of lithium
B. Prepare the client for hemodialysis
C. Encourage increased fluid intake
,D. Administer an antidiuretic hormone
Correct Answer: B
Expert Explanation: A lithium level above 2.0 mEq/L is considered severe toxicity and
may require life-saving measures. Hemodialysis is the standard treatment to rapidly
remove lithium from the blood when levels are dangerously high. The nurse should also
monitor cardiac and neurological status closely during this intervention.
3. Which behavior by a client with Borderline Personality Disorder (BPD) is an example of
‘splitting’?
A. Attempting to manipulate the staff to get extra phone time
B. Repeating exactly what the nurse says during an interview
C. Telling a nurse that they are the only one who cares, while calling
another nurse ‘evil’
D. Refusing to participate in group therapy because of anxiety
Correct Answer: C
Expert Explanation: Splitting is a primitive defense mechanism common in BPD where
individuals view people as either all good or all bad. This behavior often creates conflict
among the healthcare team as the client attempts to play staff against each other.
Consistent communication among staff is necessary to provide a unified approach to care.
, 4. A client is admitted for alcohol withdrawal. Which medication should the nurse expect to
administer to prevent seizures?
A. Disulfiram
B. Haloperidol
C. Fluoxetine
D. Lorazepam
Correct Answer: D
Expert Explanation: Benzodiazepines like lorazepam are the first-line treatment for
managing alcohol withdrawal symptoms and preventing seizures. These medications
provide a cross-tolerance to alcohol, helping to stabilize the central nervous system. The
nurse must monitor vital signs and use assessment tools like the CIWA-Ar scale to guide
dosing.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which symptoms
should the nurse look for?
A. Bradycardia and hypotension
B. Extreme talkativeness and euphoria
C. Hyporeflexia and dry skin
D. Muscle rigidity, high fever, and diaphoresis
Correct Answer: D
Behavioral Health Nursing Q&A with
Rationale | Grand Canyon University
1. A nurse is caring for a client who is taking clozapine. Which of the following laboratory
findings should the nurse prioritize?
A. Sodium level of 138 mEq/L
B. WBC count of 2,500/mm3
C. Potassium level of 4.2 mEq/L
D. Blood glucose of 105 mg/dL
Correct Answer: B
Expert Explanation: Clozapine carries a significant risk for agranulocytosis, which is a
dangerous decrease in white blood cell counts. A WBC count of 2,500/mm3 is below the
normal range and indicates that the client is at high risk for infection. The nurse must
notify the provider immediately and monitor for signs of fever or sore throat.
2. A client is experiencing lithium toxicity with a blood level of 2.2 mEq/L. What is the priority
nursing intervention?
A. Administer the next scheduled dose of lithium
B. Prepare the client for hemodialysis
C. Encourage increased fluid intake
,D. Administer an antidiuretic hormone
Correct Answer: B
Expert Explanation: A lithium level above 2.0 mEq/L is considered severe toxicity and
may require life-saving measures. Hemodialysis is the standard treatment to rapidly
remove lithium from the blood when levels are dangerously high. The nurse should also
monitor cardiac and neurological status closely during this intervention.
3. Which behavior by a client with Borderline Personality Disorder (BPD) is an example of
‘splitting’?
A. Attempting to manipulate the staff to get extra phone time
B. Repeating exactly what the nurse says during an interview
C. Telling a nurse that they are the only one who cares, while calling
another nurse ‘evil’
D. Refusing to participate in group therapy because of anxiety
Correct Answer: C
Expert Explanation: Splitting is a primitive defense mechanism common in BPD where
individuals view people as either all good or all bad. This behavior often creates conflict
among the healthcare team as the client attempts to play staff against each other.
Consistent communication among staff is necessary to provide a unified approach to care.
, 4. A client is admitted for alcohol withdrawal. Which medication should the nurse expect to
administer to prevent seizures?
A. Disulfiram
B. Haloperidol
C. Fluoxetine
D. Lorazepam
Correct Answer: D
Expert Explanation: Benzodiazepines like lorazepam are the first-line treatment for
managing alcohol withdrawal symptoms and preventing seizures. These medications
provide a cross-tolerance to alcohol, helping to stabilize the central nervous system. The
nurse must monitor vital signs and use assessment tools like the CIWA-Ar scale to guide
dosing.
5. A nurse is assessing a client for Neuroleptic Malignant Syndrome (NMS). Which symptoms
should the nurse look for?
A. Bradycardia and hypotension
B. Extreme talkativeness and euphoria
C. Hyporeflexia and dry skin
D. Muscle rigidity, high fever, and diaphoresis
Correct Answer: D
