NUR 208/NUR208 Exam 4 V1 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is providing care for a client diagnosed with Anorexia Nervosa who has begun
nutritional repletion. Which laboratory value should the nurse monitor most closely to
prevent refeeding syndrome?
A. Serum Potassium
B. Serum Sodium
C. Serum Phosphorus
D. Serum Calcium
Correct Answer: C
Expert Explanation: Refeeding syndrome is a potentially fatal complication that occurs
when fluids and electrolytes shift rapidly after nutritional intake is restarted in a severely
malnourished client. Hypophosphatemia is the hallmark of this syndrome and can lead to
cardiac failure and respiratory distress. The nurse must monitor laboratory values closely
and ensure a slow, controlled reintroduction of calories to maintain patient safety.
,2. A client with Borderline Personality Disorder (BPD) tells the night shift nurse, “The day shift
nurse is so mean, but you are the only one who truly understands me.” What is the nurse’s
best response?
A. “I’m glad you feel comfortable with me; I will talk to the day nurse for you.”
B. “All of the nurses here are dedicated professionals who want the best for you.”
C. “I understand you feel that way, but the staff works as a team to provide consistent care.”
D. “It sounds like you are upset with the day nurse. Let’s discuss your concerns in our
group session.”
Correct Answer: C
Expert Explanation: This client behavior is known as splitting, a defense mechanism
common in Borderline Personality Disorder where the client views individuals as all good
or all bad. The nurse must remain neutral and emphasize the team approach to prevent the
client from playing staff members against each other. Consistent boundary setting and clear
communication among the treatment team are essential to managing this behavior.
3. A nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
would indicate the client is experiencing the most severe form of withdrawal, Delirium
Tremens (DTs)?
A. Mild tremors and insomnia
B. Severe hypertension, tachycardia, and diaphoresis
C. Auditory hallucinations and bradycardia
,D. Visual hallucinations and seizures
Correct Answer: B
Expert Explanation: Delirium Tremens (DTs) is a medical emergency characterized by
severe autonomic hyperactivity, including tachycardia, hypertension, and fever. While
hallucinations and seizures can occur in withdrawal, the specific autonomic instability
distinguishes DTs from milder withdrawal phases. Immediate intervention with
benzodiazepines is required to prevent cardiovascular collapse or status epilepticus.
4. A nurse is teaching the family of a client with Stage 2 Alzheimer’s disease. Which of the
following behaviors is most characteristic of this middle stage of the disease?
A. Difficulty performing complex tasks like managing finances
B. Occasional forgetfulness of where keys were placed
C. Complete loss of verbal communication skills
D. Inability to recognize family members or self in the mirror
Correct Answer: A
Expert Explanation: In Stage 2 (Moderate) Alzheimer’s disease, the client experiences
significant cognitive decline that interferes with instrumental activities of daily living
(IADLs). This includes difficulty with complex tasks such as paying bills, planning meals, or
traveling alone to familiar places. Total loss of recognition (agnosia) and loss of speech
generally occur in the late or terminal stage of the disease.
, 5. A client with Bulimia Nervosa is admitted to the psychiatric unit. Which physical
assessment finding should the nurse anticipate?
A. Parotid gland swelling and dental caries
B. Lanugo and bradycardia
C. Extreme emaciation and hypotension
D. Yellowish skin and cold extremities
Correct Answer: A
Expert Explanation: Clients with Bulimia Nervosa often maintain a normal or near-normal
weight, but show physical signs related to self-induced vomiting. Chronic vomiting causes
irritation and swelling of the parotid glands and the acid from the stomach leads to erosion
of dental enamel. Lanugo and extreme emaciation are more commonly associated with the
restrictive type of Anorexia Nervosa.
6. A nurse is evaluating a client who has experienced a sudden job loss and is now unable to
sleep or eat. Which type of crisis is the client experiencing?
A. Maturational crisis
B. Situational crisis
C. Adventitious crisis
D. Developmental crisis
Correct Answer: B
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is providing care for a client diagnosed with Anorexia Nervosa who has begun
nutritional repletion. Which laboratory value should the nurse monitor most closely to
prevent refeeding syndrome?
A. Serum Potassium
B. Serum Sodium
C. Serum Phosphorus
D. Serum Calcium
Correct Answer: C
Expert Explanation: Refeeding syndrome is a potentially fatal complication that occurs
when fluids and electrolytes shift rapidly after nutritional intake is restarted in a severely
malnourished client. Hypophosphatemia is the hallmark of this syndrome and can lead to
cardiac failure and respiratory distress. The nurse must monitor laboratory values closely
and ensure a slow, controlled reintroduction of calories to maintain patient safety.
,2. A client with Borderline Personality Disorder (BPD) tells the night shift nurse, “The day shift
nurse is so mean, but you are the only one who truly understands me.” What is the nurse’s
best response?
A. “I’m glad you feel comfortable with me; I will talk to the day nurse for you.”
B. “All of the nurses here are dedicated professionals who want the best for you.”
C. “I understand you feel that way, but the staff works as a team to provide consistent care.”
D. “It sounds like you are upset with the day nurse. Let’s discuss your concerns in our
group session.”
Correct Answer: C
Expert Explanation: This client behavior is known as splitting, a defense mechanism
common in Borderline Personality Disorder where the client views individuals as all good
or all bad. The nurse must remain neutral and emphasize the team approach to prevent the
client from playing staff members against each other. Consistent boundary setting and clear
communication among the treatment team are essential to managing this behavior.
3. A nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
would indicate the client is experiencing the most severe form of withdrawal, Delirium
Tremens (DTs)?
A. Mild tremors and insomnia
B. Severe hypertension, tachycardia, and diaphoresis
C. Auditory hallucinations and bradycardia
,D. Visual hallucinations and seizures
Correct Answer: B
Expert Explanation: Delirium Tremens (DTs) is a medical emergency characterized by
severe autonomic hyperactivity, including tachycardia, hypertension, and fever. While
hallucinations and seizures can occur in withdrawal, the specific autonomic instability
distinguishes DTs from milder withdrawal phases. Immediate intervention with
benzodiazepines is required to prevent cardiovascular collapse or status epilepticus.
4. A nurse is teaching the family of a client with Stage 2 Alzheimer’s disease. Which of the
following behaviors is most characteristic of this middle stage of the disease?
A. Difficulty performing complex tasks like managing finances
B. Occasional forgetfulness of where keys were placed
C. Complete loss of verbal communication skills
D. Inability to recognize family members or self in the mirror
Correct Answer: A
Expert Explanation: In Stage 2 (Moderate) Alzheimer’s disease, the client experiences
significant cognitive decline that interferes with instrumental activities of daily living
(IADLs). This includes difficulty with complex tasks such as paying bills, planning meals, or
traveling alone to familiar places. Total loss of recognition (agnosia) and loss of speech
generally occur in the late or terminal stage of the disease.
, 5. A client with Bulimia Nervosa is admitted to the psychiatric unit. Which physical
assessment finding should the nurse anticipate?
A. Parotid gland swelling and dental caries
B. Lanugo and bradycardia
C. Extreme emaciation and hypotension
D. Yellowish skin and cold extremities
Correct Answer: A
Expert Explanation: Clients with Bulimia Nervosa often maintain a normal or near-normal
weight, but show physical signs related to self-induced vomiting. Chronic vomiting causes
irritation and swelling of the parotid glands and the acid from the stomach leads to erosion
of dental enamel. Lanugo and extreme emaciation are more commonly associated with the
restrictive type of Anorexia Nervosa.
6. A nurse is evaluating a client who has experienced a sudden job loss and is now unable to
sleep or eat. Which type of crisis is the client experiencing?
A. Maturational crisis
B. Situational crisis
C. Adventitious crisis
D. Developmental crisis
Correct Answer: B
