Behavioral Health 2 Practice Questions

Module 7-10 content

A client with schizophrenia says, "The voices are telling me to jump out the window." What is the nurse's priority action?

A. Ask the client why they want to jump
B. Assess whether the client intends to act on the voices
C. Tell the client the voices are not real
D. Administer PRN medication later

B. Assess whether the client intends to act on the voices

Rationale: Command hallucinations are a psychiatric emergency. The nurse must determine if the client can resist the command and assess immediate safety risks

A nurse is caring for a client experiencing auditory hallucinations. Which interventions are appropriate? SATA

A. Encourage listening to music with headphones
B. Validate that the voices are real
C. Acknowledge the client's fear
D. Encourage conversation with others
E. Argue with the hallucination

A, C, D

Rationale:

• Music provides competing auditory stimulation.

• Acknowledge feelings.

• Encourage social interaction.

• Never validate hallucinations.

• Never argue about hallucinations.

Which assessment finding requires immediate intervention?

A. Grandiose delusion B. Social withdrawal C. Command hallucination directing self-harm D. Flat affect

C

Rationale: Safety threats always take priority over psychosocial symptoms. Command hallucinations involving self-harm require immediate intervention.

A client states, "The FBI poisoned my lunch." What is the best response?

A. "That's impossible." B. "Why do you think that?" C. "That sounds frightening for you." D. "You're being paranoid."

C

Rationale: Validate feelings without validating the delusion. Direct confrontation increases distrust

The nurse suspects water intoxication in a client with schizophrenia. Which assessment finding supports this concern?

A. Weight loss B. Confusion and seizures C. Dry skin D. Bradycardia

B

Rationale: Compulsive polydipsia can cause hyponatremia, confusion, delirium, seizures, and coma

A client taking haloperidol suddenly develops a twisted neck and difficulty breathing. What should the nurse do first?

A. Reassure the client B. Give benztropine C. Encourage fluids D. Reassess in an hour

B

Rationale: Acute dystonia is an EPS emergency. Laryngeal involvement threatens the airway and requires immediate benztropine or diphenhydramine

Which findings indicate Neuroleptic Malignant Syndrome (NMS)? SATA

A. Temperature 104°F

B. Lead-pipe rigidity

C. Tachycardia

D. Polyuria

E. Altered level of consciousness

A, B, C, E

Rationale: Classic NMS:

• Hyperpyrexia

• Muscle rigidity

• Autonomic instability

• Altered consciousness

A client receiving antipsychotics develops NMS. What is the priority nursing action?

A. Encourage fluids B. Hold all antipsychotics C. Obtain weight D. Reassess later

B

Rationale: First action: stop antipsychotics immediately and notify the provider.

A client taking clozapine reports a sore throat and fever. What should the nurse do?

A. Recommend acetaminophen

B. Notify the provider immediately

C. Encourage rest

D. Schedule follow-up next month

B

Rationale: Clozapine can cause agranulocytosis. Fever and sore throat may indicate neutropenia.

Which symptoms are associated with tardive dyskinesia? SATA

A. Lip smacking

B. Tongue writhing

C. Facial grimacing

D. Bradycardia

E. Involuntary limb movement

A, B, C, E

Rationale: TD causes involuntary repetitive movements, especially involving the face, tongue, and extremities.

A manic client has not slept for 4 days and constantly paces. Which intervention is the priority?

A. Group therapy

B. High-protein finger foods

C. Family meeting

D. Art therapy

B

Rationale: Mania places clients at risk for dehydration and physical exhaustion. Meeting physiological needs is priority.

Which nursing action is most appropriate for an acutely manic client?

A. Provide a stimulating environment

B. Encourage competitive games

C. Place in a quiet area

D. Allow unlimited visitors

C

Rationale: A low-stimulation environment decreases agitation and escalation.

A nurse is caring for a client experiencing mania. Which findings are expected? SATA

A. Grandiosity

B. Pressured speech

C. Excessive sleep

D. Flight of ideas E. Risky behaviors

A, B, D, E

Rationale: DIG FAST: Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, Talkativeness

A client taking lithium reports vomiting, diarrhea, and coarse hand tremors. What should the nurse do first?

A. Give next dose

B. Hold lithium and notify provider

C. Increase sodium restriction

D. Encourage caffeine

B

Rationale: These signs indicate lithium toxicity. The medication should be withheld immediately.

Which teaching should the nurse include for a client taking lithium? SATA

A. Maintain consistent sodium intake

B. Drink 1500-3000 mL/day

C. Avoid dehydration

D. Take ibuprofen daily

E. Contact provider for diarrhea

A, B, C, E

Rationale: Dehydration and sodium imbalance increase lithium toxicity risk. NSAIDs may increase lithium levels

A lithium level is 2.6 mEq/L. Which intervention is anticipated?

A. Discharge home B. Hemodialysis C. Increase lithium dose D. Encourage exercise

B

Rationale: Levels above 2.5 mEq/L indicate severe toxicity and may require hemodialysis.

Which client should the nurse see first?

A. Depression with poor appetite B. Depression requesting sleeping medication C. Bipolar client stating, "I have a gun at home." D. Client refusing breakfast

C

Rationale: Presence of a suicide plan and means indicates highest risk.

Which questions should the nurse ask when assessing suicide risk? SATA

A. "Have you thought about ending your life?"

B. "Do you have a plan?"

C. "Do you have the means?"

D. "What prevents you from acting?"

E. "Wouldn't your family be sad?"

A, B, C, D

Rationale: Direct questioning is essential for suicide assessment. Avoid guilt-inducing statements

An older adult becomes suddenly confused and disoriented over several hours. What is the nurse's priority interpretation?

A. Normal aging B. Dementia progression C. Delirium D. Depression

C

Rationale: Sudden onset and fluctuating cognition are hallmarks of delirium and require urgent evaluation.

A client with dementia suddenly becomes aggressive. What should the nurse assess first?

A. Family dynamics B. Pain C. Personality disorder D. Childhood trauma

B

Rationale: Behavioral changes in dementia often result from pain or unmet physical needs.

An unresponsive client has pinpoint pupils and respirations of 6/min. What is the priority action?

A. Obtain history B. Naloxone administration C. Assess diet D. Obtain weight

B

Rationale: Classic opioid overdose requires immediate airway support and naloxone administration

Place the interventions for opioid overdose in priority order.

1. Airway support

2. Naloxone administration

3. Continuous monitoring

4. Oxygenation

1 → 4 → 2 → 3

Rationale: ABCs always come first. Naloxone is given after airway and breathing support are initiated. Re-sedation may occur.

Which findings suggest alcohol withdrawal? SATA

A. Tremors B. Hallucinations C. Tachycardia D. Hypertension E. Bradycardia

A, B, C, D

Rationale: Alcohol withdrawal causes autonomic hyperactivity and may progress to hallucinations and seizures

A client with bulimia has a potassium level of 2.9 mEq/L. Why is this finding concerning?

A. Fluid overload B. Cardiac dysrhythmias C. Hyperglycemia D. Hypertension

✅ B

Rationale: Hypokalemia is the leading cause of fatal dysrhythmias in clients with bulimia.

Which are signs of refeeding syndrome? SATA

A. Hypophosphatemia B. Hypokalemia C. Pulmonary edema D. Heart failure E. Hypercalcemia

✅ A, B, C, D

Rationale: Rapid nutritional replacement can cause dangerous electrolyte shifts and cardiovascular collapse.

A client with anorexia gains 6 pounds in one week during treatment. What is the nurse's priority concern?

A. Successful treatment B. Pulmonary edema C. Hyperthyroidism D. Infection

✅ B

Rationale: Rapid weight gain may indicate fluid overload and risk for pulmonary edema during nutritional restoration.

A client taking sertraline and phenelzine develops hyperthermia, tremors, agitation, and diarrhea. Which condition should the nurse suspect first?

A. NMS
B. Lithium toxicity
C. Serotonin syndrome
D. Alcohol withdrawal

C. Serotonin syndrome

Rationale: Serotonin syndrome is caused by excessive serotonin activity and presents with hyperthermia, agitation, tremors, hyperreflexia, diarrhea, and altered mental status.

A nurse suspects serotonin syndrome. What is the priority intervention?

A. Encourage fluids B. Stop serotonergic medications C. Decrease room stimulation D. Reassess in 30 minutes

✅ B. Stop serotonergic medications

Rationale: The first intervention is immediate discontinuation of the offending agents and emergency treatment.

Which manifestations are expected with serotonin syndrome? SATA

A. Hyperreflexia B. Myoclonus C. Diarrhea D. Hyperthermia E. Bradycardia

✅ A, B, C, D

Rationale: Common findings include:

• Hyperreflexia

• Muscle spasms/myoclonus

• Hyperthermia

• Diarrhea

• Tachycardia and hypertension

A client taking an MAOI reports eating pepperoni pizza and now has a severe headache and elevated blood pressure. Which complication is most concerning?

A. Stroke B. Hypoglycemia C. Dehydration D. Sepsis

✅ A. Stroke

Rationale: Tyramine ingestion with MAOIs can trigger hypertensive crisis and intracranial hemorrhage.

The nurse teaches a client taking phenelzine to avoid which foods? SATA

A. Aged cheese B. Salami C. Sauerkraut D. Soy sauce E. Cottage cheese

✅ A, B, C, D

Rationale: High tyramine foods increase the risk for hypertensive crisis. Cottage cheese is generally permitted.

Following ECT, which assessment is the priority before offering food?

A. Mood B. Weight C. Gag reflex D. Memory

✅ C. Gag reflex

Rationale: Airway protection is priority after anesthesia and ECT. Verify gag reflex before oral intake

A client with borderline personality disorder cuts their arm. What is the nurse's priority action?

A. Explore childhood trauma

B. Assess injury and ensure safety

C. Ignore the behavior

D. Praise the client

✅ B. Assess injury and ensure safety

Rationale: Safety always comes first. Risk for self-mutilation is the priority diagnosis

A nurse is dressing a self-inflicted wound in a client with borderline personality disorder. Which approach is appropriate?

A. Dramatically express concern B. Use a matter-of-fact approach C. Provide special privileges D. Focus attention on the injury

✅ B. Use a matter-of-fact approach

Rationale: Avoid reinforcing self-harm through excessive attention. Provide neutral wound care.

Which therapy has the strongest evidence for borderline personality disorder?

A. DBT

B. ECT

C. Exposure therapy

D. Hypnosis

✅ A. DBT

Rationale: Dialectical Behavior Therapy is the gold-standard treatment for emotional regulation and self-harm reduction.

A client says, "You're the only nurse who actually cares about me. The others are terrible." What should the nurse identify?

A. Projection

B. Splitting

C. Hallucination

D. Thought blocking

✅ B. Splitting

Rationale: Splitting involves viewing people as all good or all bad and may divide staff members.

An older adult with dementia suddenly becomes confused and develops visual hallucinations. What should the nurse suspect first?

A. Expected dementia progression

B. Delirium superimposed on dementia

C. Schizophrenia

D. Depression

✅ B. Delirium superimposed on dementia

Rationale: A sudden change from baseline is not normal dementia progression and requires medical evaluation.

Which interventions help prevent delirium in hospitalized older adults? SATA

A. Ensure hearing aids are used

B. Promote hydration

C. Use restraints frequently

D. Ensure eyeglasses are available

E. Manage pain

✅ A, B, D, E

Rationale: Sensory aids, hydration, pain control, and orientation reduce delirium risk. Restraints increase confusion.

A client with Alzheimer's disease repeatedly asks where their deceased spouse is. What is the best nursing response?

A. "Your spouse died years ago."

B. "You already asked me."

C. "You seem worried about your spouse."

D. Walk away

✅ C

Rationale: Validate emotions rather than arguing or forcing orientation

A nurse gives a client with Alzheimer's disease an instruction. How long should the nurse wait before assisting?

A. Immediately B. 1 second C. 5 seconds D. 15 seconds

C. 5 seconds

Rationale: Patients need additional processing time before responding