NSG 322/NSG322 Exam 4 V3 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A client is admitted to the detoxification unit with a diagnosis of chronic alcoholism. Which
vitamin should the nurse anticipate administering to prevent Wernicke-Korsakoff syndrome?
A. Vitamin B1 (Thiamine)
B. Vitamin B12 (Cyanocobalamin)
C. Vitamin C (Ascorbic acid)
D. Vitamin D (Cholecalciferol)
Correct Answer: A
Expert Explanation: Thiamine deficiency is a common consequence of chronic alcohol
abuse and can lead to severe neurological complications. Wernicke-Korsakoff syndrome is
a serious manifestation of this deficiency characterized by ataxia, confusion, and memory
loss. Administering Vitamin B1 early in treatment helps prevent permanent brain damage
and neurological decline in these patients.
,2. A nurse is caring for a client diagnosed with Anorexia Nervosa. Which assessment finding is
considered a medical emergency requiring immediate hospitalization?
A. Heart rate of 38 beats per minute
B. Body Mass Index (BMI) of 17
C. Fine, downy hair (lanugo) on the back
D. Client report of feeling fat despite being underweight
Correct Answer: A
Expert Explanation: Severe bradycardia, such as a heart rate below 40 bpm, indicates
significant cardiovascular instability in patients with Anorexia Nervosa. This condition
poses a high risk for sudden cardiac arrest or lethal arrhythmias due to electrolyte
imbalances and muscle wasting. While low BMI and lanugo are typical signs, they do not
represent the same level of immediate life-threatening urgency as bradycardia.
3. A client with Borderline Personality Disorder often categorizes staff members as either ‘all
good’ or ‘all bad.’ What is the term for this defense mechanism?
A. Projective identification
B. Intellectualization
C. Splitting
D. Reaction formation
Correct Answer: C
Expert Explanation: Splitting is a primitive defense mechanism where individuals are
unable to integrate the positive and negative qualities of others into a cohesive image. This
,results in the client viewing people as either entirely nurturing or entirely malevolent,
which often leads to conflict within the healthcare team. Consistent communication and set
boundaries among staff are essential to manage this behavior effectively.
4. The nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
typically appears within 6 to 8 hours after the last drink?
A. Visual hallucinations
B. Fine tremors and irritability
C. Generalized tonic-clonic seizures
D. Severe hypotension
Correct Answer: B
Expert Explanation: Early withdrawal symptoms from alcohol generally include mild
tremors, anxiety, tachycardia, and irritability. These symptoms usually manifest within the
first few hours of abstinence as the central nervous system becomes hyper-irritable.
Monitoring for these early signs is crucial to prevent the progression to delirium tremens
or withdrawal seizures.
, 5. A client is prescribed Disulfiram (Antabuse) for alcohol abstinence. What is the most
important teaching point for this medication?
A. The medication should be taken only when the client feels the urge to drink.
B. Drowsiness is a sign of toxicity and should be reported immediately.
C. The client must avoid all products containing alcohol, including mouthwash and cough
syrup.
D. The drug takes effect within 30 minutes of the first dose.
Correct Answer: C
Expert Explanation: Disulfiram works by causing an extremely unpleasant reaction when
even small amounts of alcohol are ingested. Clients must be educated to read labels
carefully for hidden alcohol in foods, hygiene products, and over-the-counter medicines.
Failure to avoid these products can result in severe nausea, vomiting, palpitations, and
potentially cardiovascular collapse.
6. Which personality disorder is characterized by a pervasive pattern of disregard for, and
violation of, the rights of others?
A. Narcissistic Personality Disorder
B. Antisocial Personality Disorder
C. Histrionic Personality Disorder
D. Avoidant Personality Disorder
Correct Answer: B
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A client is admitted to the detoxification unit with a diagnosis of chronic alcoholism. Which
vitamin should the nurse anticipate administering to prevent Wernicke-Korsakoff syndrome?
A. Vitamin B1 (Thiamine)
B. Vitamin B12 (Cyanocobalamin)
C. Vitamin C (Ascorbic acid)
D. Vitamin D (Cholecalciferol)
Correct Answer: A
Expert Explanation: Thiamine deficiency is a common consequence of chronic alcohol
abuse and can lead to severe neurological complications. Wernicke-Korsakoff syndrome is
a serious manifestation of this deficiency characterized by ataxia, confusion, and memory
loss. Administering Vitamin B1 early in treatment helps prevent permanent brain damage
and neurological decline in these patients.
,2. A nurse is caring for a client diagnosed with Anorexia Nervosa. Which assessment finding is
considered a medical emergency requiring immediate hospitalization?
A. Heart rate of 38 beats per minute
B. Body Mass Index (BMI) of 17
C. Fine, downy hair (lanugo) on the back
D. Client report of feeling fat despite being underweight
Correct Answer: A
Expert Explanation: Severe bradycardia, such as a heart rate below 40 bpm, indicates
significant cardiovascular instability in patients with Anorexia Nervosa. This condition
poses a high risk for sudden cardiac arrest or lethal arrhythmias due to electrolyte
imbalances and muscle wasting. While low BMI and lanugo are typical signs, they do not
represent the same level of immediate life-threatening urgency as bradycardia.
3. A client with Borderline Personality Disorder often categorizes staff members as either ‘all
good’ or ‘all bad.’ What is the term for this defense mechanism?
A. Projective identification
B. Intellectualization
C. Splitting
D. Reaction formation
Correct Answer: C
Expert Explanation: Splitting is a primitive defense mechanism where individuals are
unable to integrate the positive and negative qualities of others into a cohesive image. This
,results in the client viewing people as either entirely nurturing or entirely malevolent,
which often leads to conflict within the healthcare team. Consistent communication and set
boundaries among staff are essential to manage this behavior effectively.
4. The nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
typically appears within 6 to 8 hours after the last drink?
A. Visual hallucinations
B. Fine tremors and irritability
C. Generalized tonic-clonic seizures
D. Severe hypotension
Correct Answer: B
Expert Explanation: Early withdrawal symptoms from alcohol generally include mild
tremors, anxiety, tachycardia, and irritability. These symptoms usually manifest within the
first few hours of abstinence as the central nervous system becomes hyper-irritable.
Monitoring for these early signs is crucial to prevent the progression to delirium tremens
or withdrawal seizures.
, 5. A client is prescribed Disulfiram (Antabuse) for alcohol abstinence. What is the most
important teaching point for this medication?
A. The medication should be taken only when the client feels the urge to drink.
B. Drowsiness is a sign of toxicity and should be reported immediately.
C. The client must avoid all products containing alcohol, including mouthwash and cough
syrup.
D. The drug takes effect within 30 minutes of the first dose.
Correct Answer: C
Expert Explanation: Disulfiram works by causing an extremely unpleasant reaction when
even small amounts of alcohol are ingested. Clients must be educated to read labels
carefully for hidden alcohol in foods, hygiene products, and over-the-counter medicines.
Failure to avoid these products can result in severe nausea, vomiting, palpitations, and
potentially cardiovascular collapse.
6. Which personality disorder is characterized by a pervasive pattern of disregard for, and
violation of, the rights of others?
A. Narcissistic Personality Disorder
B. Antisocial Personality Disorder
C. Histrionic Personality Disorder
D. Avoidant Personality Disorder
Correct Answer: B
