NSG 322/NSG322 Exam 2 V1 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client with Major Depressive Disorder who recently started taking
Fluoxetine. Which of the following statements by the client requires immediate intervention?
A. I have been feeling a bit more energetic lately.
B. I am having trouble falling asleep at night.
C. My mouth feels very dry throughout the day.
D. I finally have the energy to follow through with my plan.
Correct Answer: D
Expert Explanation: When a client with depression begins to feel more energetic, the risk
of suicide increases because they now have the physical energy to carry out a plan. The
nurse must immediately assess for a specific suicide plan and intent. This shift in energy is
a critical warning sign that requires close monitoring and safety precautions.
,2. A client is prescribed Lithium Carbonate for the treatment of Bipolar I Disorder. Which of
the following lab results should the nurse report to the provider immediately?
A. Lithium level of 0.8 mEq/L
B. Lithium level of 1.7 mEq/L
C. Sodium level of 140 mEq/L
D. Creatinine level of 1.0 mg/dL
Correct Answer: B
Expert Explanation: A lithium level of 1.7 mEq/L is above the therapeutic range of 0.6 to
1.2 mEq/L and indicates early toxicity. The nurse should hold the dose and notify the
healthcare provider to prevent further toxicity symptoms like seizures or cardiac
dysrhythmias. Maintaining adequate fluid and sodium intake is essential while on this
medication to keep levels stable.
3. A nurse is assessing a client with Anorexia Nervosa. Which of the following clinical findings
should the nurse expect?
A. Amenorrhea and lanugo
B. Hyperkalemia and metabolic acidosis
C. Tachycardia and hypertension
D. Increased bone density
Correct Answer: A
Expert Explanation: Amenorrhea is a common finding in Anorexia Nervosa due to
hormonal imbalances caused by low body weight. Lanugo, which is fine, downy hair, grows
, on the body as a compensatory mechanism to provide warmth in a malnourished state.
Other common findings include bradycardia, hypotension, and generalized weakness.
4. A client diagnosed with Obsessive-Compulsive Disorder (OCD) spends 45 minutes washing
their hands before every meal. Which nursing intervention is most appropriate during the
initial phase of treatment?
A. Prohibiting the client from using the bathroom before meals
B. Allowing the client enough time to perform the ritual
C. Explaining that the hands are already clean
D. Administering a PRN sedative before mealtime
Correct Answer: B
Expert Explanation: During the initial phase of treatment for OCD, the nurse should allow
the client to perform rituals to prevent extreme anxiety levels. Restricting rituals early in
treatment can lead to a panic attack and build mistrust between the client and the nurse.
Over time, the nurse will work with the client on time-limiting the rituals and developing
alternative coping mechanisms.
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client with Major Depressive Disorder who recently started taking
Fluoxetine. Which of the following statements by the client requires immediate intervention?
A. I have been feeling a bit more energetic lately.
B. I am having trouble falling asleep at night.
C. My mouth feels very dry throughout the day.
D. I finally have the energy to follow through with my plan.
Correct Answer: D
Expert Explanation: When a client with depression begins to feel more energetic, the risk
of suicide increases because they now have the physical energy to carry out a plan. The
nurse must immediately assess for a specific suicide plan and intent. This shift in energy is
a critical warning sign that requires close monitoring and safety precautions.
,2. A client is prescribed Lithium Carbonate for the treatment of Bipolar I Disorder. Which of
the following lab results should the nurse report to the provider immediately?
A. Lithium level of 0.8 mEq/L
B. Lithium level of 1.7 mEq/L
C. Sodium level of 140 mEq/L
D. Creatinine level of 1.0 mg/dL
Correct Answer: B
Expert Explanation: A lithium level of 1.7 mEq/L is above the therapeutic range of 0.6 to
1.2 mEq/L and indicates early toxicity. The nurse should hold the dose and notify the
healthcare provider to prevent further toxicity symptoms like seizures or cardiac
dysrhythmias. Maintaining adequate fluid and sodium intake is essential while on this
medication to keep levels stable.
3. A nurse is assessing a client with Anorexia Nervosa. Which of the following clinical findings
should the nurse expect?
A. Amenorrhea and lanugo
B. Hyperkalemia and metabolic acidosis
C. Tachycardia and hypertension
D. Increased bone density
Correct Answer: A
Expert Explanation: Amenorrhea is a common finding in Anorexia Nervosa due to
hormonal imbalances caused by low body weight. Lanugo, which is fine, downy hair, grows
, on the body as a compensatory mechanism to provide warmth in a malnourished state.
Other common findings include bradycardia, hypotension, and generalized weakness.
4. A client diagnosed with Obsessive-Compulsive Disorder (OCD) spends 45 minutes washing
their hands before every meal. Which nursing intervention is most appropriate during the
initial phase of treatment?
A. Prohibiting the client from using the bathroom before meals
B. Allowing the client enough time to perform the ritual
C. Explaining that the hands are already clean
D. Administering a PRN sedative before mealtime
Correct Answer: B
Expert Explanation: During the initial phase of treatment for OCD, the nurse should allow
the client to perform rituals to prevent extreme anxiety levels. Restricting rituals early in
treatment can lead to a panic attack and build mistrust between the client and the nurse.
Over time, the nurse will work with the client on time-limiting the rituals and developing
alternative coping mechanisms.
