NUR 208/NUR208 Exam 4 V3 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with Anorexia Nervosa. Which physical finding should the
nurse expect?
A. Tachycardia
B. Hyperthermia
C. Hypertension
D. Lanugo
Correct Answer: D
Expert Explanation: Lanugo is a fine, downy hair growth that occurs as a compensatory
mechanism to keep the body warm during starvation. Clients with anorexia often exhibit
bradycardia and hypotension due to the body’s reduced metabolic rate. Assessing for these
physical markers is crucial in evaluating the severity of malnutrition.
2. A client with Borderline Personality Disorder is using ‘splitting’ when talking to staff. How
should the nurse respond?
A. Facilitate staff meetings to maintain consistency
B. Agree with the client’s assessment of other staff
C. Allow the client to choose their favorite nurse
,D. Avoid the client to prevent manipulation
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client perceives
individuals as either all good or all bad. To counteract this, the nursing staff must maintain
open communication and provide a consistent approach to care. This prevents the client
from playing staff members against one another and maintains a therapeutic environment.
3. A nurse is caring for a client experiencing alcohol withdrawal. Which medication is the gold
standard for preventing seizures?
A. Methadone
B. Chlordiazepoxide
C. Varenicline
D. Disulfiram
Correct Answer: B
Expert Explanation: Benzodiazepines like Chlordiazepoxide are the primary treatment for
alcohol withdrawal symptoms. They help stabilize vital signs and increase the seizure
threshold during the detoxification process. Monitoring the client’s CIWA-Ar score is
essential to determine the appropriate dosage of these medications.
4. Which finding is characteristic of a client with Antisocial Personality Disorder?
A. Extreme shyness and fear of rejection
, B. Lack of remorse for hurting others
C. Intense fear of being alone
D. Magical thinking and odd beliefs
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is characterized by a pervasive
pattern of disregard for the rights of others. Individuals often engage in deceitful or illegal
behaviors without experiencing guilt or remorse. Treatment is challenging because these
clients rarely seek help unless legally mandated or for personal gain.
5. A client with Bulimia Nervosa is admitted to the unit. Which laboratory value should the
nurse prioritize?
A. Potassium 2.8 mEq/L
B. Sodium 138 mEq/L
C. Hemoglobin 13 g/dL
D. BUN 15 mg/dL
Correct Answer: A
Expert Explanation: Hypokalemia is a frequent and dangerous complication of frequent
purging in Bulimia Nervosa. Low potassium levels can lead to life-threatening cardiac
dysrhythmias and muscle weakness. The nurse must monitor electrolyte panels closely and
report abnormal values to the provider immediately.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is assessing a client with Anorexia Nervosa. Which physical finding should the
nurse expect?
A. Tachycardia
B. Hyperthermia
C. Hypertension
D. Lanugo
Correct Answer: D
Expert Explanation: Lanugo is a fine, downy hair growth that occurs as a compensatory
mechanism to keep the body warm during starvation. Clients with anorexia often exhibit
bradycardia and hypotension due to the body’s reduced metabolic rate. Assessing for these
physical markers is crucial in evaluating the severity of malnutrition.
2. A client with Borderline Personality Disorder is using ‘splitting’ when talking to staff. How
should the nurse respond?
A. Facilitate staff meetings to maintain consistency
B. Agree with the client’s assessment of other staff
C. Allow the client to choose their favorite nurse
,D. Avoid the client to prevent manipulation
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client perceives
individuals as either all good or all bad. To counteract this, the nursing staff must maintain
open communication and provide a consistent approach to care. This prevents the client
from playing staff members against one another and maintains a therapeutic environment.
3. A nurse is caring for a client experiencing alcohol withdrawal. Which medication is the gold
standard for preventing seizures?
A. Methadone
B. Chlordiazepoxide
C. Varenicline
D. Disulfiram
Correct Answer: B
Expert Explanation: Benzodiazepines like Chlordiazepoxide are the primary treatment for
alcohol withdrawal symptoms. They help stabilize vital signs and increase the seizure
threshold during the detoxification process. Monitoring the client’s CIWA-Ar score is
essential to determine the appropriate dosage of these medications.
4. Which finding is characteristic of a client with Antisocial Personality Disorder?
A. Extreme shyness and fear of rejection
, B. Lack of remorse for hurting others
C. Intense fear of being alone
D. Magical thinking and odd beliefs
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is characterized by a pervasive
pattern of disregard for the rights of others. Individuals often engage in deceitful or illegal
behaviors without experiencing guilt or remorse. Treatment is challenging because these
clients rarely seek help unless legally mandated or for personal gain.
5. A client with Bulimia Nervosa is admitted to the unit. Which laboratory value should the
nurse prioritize?
A. Potassium 2.8 mEq/L
B. Sodium 138 mEq/L
C. Hemoglobin 13 g/dL
D. BUN 15 mg/dL
Correct Answer: A
Expert Explanation: Hypokalemia is a frequent and dangerous complication of frequent
purging in Bulimia Nervosa. Low potassium levels can lead to life-threatening cardiac
dysrhythmias and muscle weakness. The nurse must monitor electrolyte panels closely and
report abnormal values to the provider immediately.
