NSG221/NSG 221 Exam 4 V2 | Mental
Health Nursing Q&A with Rationale |
Herzing University
1. A nurse is assessing a client with Borderline Personality Disorder. Which of the following
behaviors is the most characteristic of this diagnosis?
A. Extreme fear of social situations and public speaking.
B. Preoccupation with orderliness, perfectionism, and control.
C. Demonstration of splitting behavior in relationships with staff.
D. Lack of remorse after violating the rights of others.
Correct Answer: C
Rationale: Splitting is a common defense mechanism used by clients with Borderline
Personality Disorder, where they view individuals as either all good or all bad. This
behavior often creates conflict among nursing staff members as the client seeks to
manipulate relationships. Nursing care must focus on setting firm limits and maintaining
consistent communication across the healthcare team.
2. A client is admitted to the psychiatric unit with a diagnosis of Anorexia Nervosa. Which
physical assessment finding is most likely to be observed?
A. Hypertension and tachycardia.
B. Presence of lanugo on the back and extremities.
,C. Hyperkalemia and metabolic acidosis.
D. Increased core body temperature.
Correct Answer: B
Rationale: Lanugo is the growth of fine, downy hair on the body as a compensatory
mechanism to provide warmth when body fat is depleted. Clients with anorexia nervosa
typically present with bradycardia and hypotension rather than hypertension. This
condition is a result of severe malnutrition and the body’s attempt to conserve energy in a
starved state.
3. The nurse is providing education to a client starting Disulfiram (Antabuse) for alcohol use
disorder. Which instruction is the most critical for the nurse to include?
A. Avoid all products containing alcohol, including mouthwash and aftershave.
B. The medication should be taken only when you feel an urge to drink.
C. Stop the medication immediately if you experience a metallic taste.
D. You can safely consume alcohol 24 hours after your last dose.
Correct Answer: A
Rationale: Disulfiram causes a severe adverse reaction when even small amounts of
alcohol are ingested or absorbed through the skin. Clients must be educated to read labels
on products like cough syrups, vinegars, and topical solutions. The reaction can include
flushing, nausea, vomiting, and potentially life-threatening cardiovascular effects.
, 4. A client with Antisocial Personality Disorder is being treated in a group setting. Which of
the following traits should the nurse expect to observe?
A. Lack of empathy and disregard for the rights of others.
B. Social inhibition and feelings of inadequacy.
C. Excessive emotionality and attention-seeking behavior.
D. Magical thinking and odd perceptual distortions.
Correct Answer: A
Rationale: Antisocial Personality Disorder is characterized by a persistent pattern of
ignoring social norms and violating the rights of others. These clients often lack remorse
for their actions and can be highly manipulative to achieve their own goals. The nurse
should focus on setting clear boundaries and consequences for inappropriate behavior
within the therapeutic environment.
5. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
findings indicates the client is developing Delirium Tremens (DTs)?
A. Bradycardia and somnolence.
B. Hallucinations, hypertension, and tremors.
C. Hypotension and decreased deep tendon reflexes.
D. Hypoglycemia and dry mucous membranes.
Correct Answer: B
Health Nursing Q&A with Rationale |
Herzing University
1. A nurse is assessing a client with Borderline Personality Disorder. Which of the following
behaviors is the most characteristic of this diagnosis?
A. Extreme fear of social situations and public speaking.
B. Preoccupation with orderliness, perfectionism, and control.
C. Demonstration of splitting behavior in relationships with staff.
D. Lack of remorse after violating the rights of others.
Correct Answer: C
Rationale: Splitting is a common defense mechanism used by clients with Borderline
Personality Disorder, where they view individuals as either all good or all bad. This
behavior often creates conflict among nursing staff members as the client seeks to
manipulate relationships. Nursing care must focus on setting firm limits and maintaining
consistent communication across the healthcare team.
2. A client is admitted to the psychiatric unit with a diagnosis of Anorexia Nervosa. Which
physical assessment finding is most likely to be observed?
A. Hypertension and tachycardia.
B. Presence of lanugo on the back and extremities.
,C. Hyperkalemia and metabolic acidosis.
D. Increased core body temperature.
Correct Answer: B
Rationale: Lanugo is the growth of fine, downy hair on the body as a compensatory
mechanism to provide warmth when body fat is depleted. Clients with anorexia nervosa
typically present with bradycardia and hypotension rather than hypertension. This
condition is a result of severe malnutrition and the body’s attempt to conserve energy in a
starved state.
3. The nurse is providing education to a client starting Disulfiram (Antabuse) for alcohol use
disorder. Which instruction is the most critical for the nurse to include?
A. Avoid all products containing alcohol, including mouthwash and aftershave.
B. The medication should be taken only when you feel an urge to drink.
C. Stop the medication immediately if you experience a metallic taste.
D. You can safely consume alcohol 24 hours after your last dose.
Correct Answer: A
Rationale: Disulfiram causes a severe adverse reaction when even small amounts of
alcohol are ingested or absorbed through the skin. Clients must be educated to read labels
on products like cough syrups, vinegars, and topical solutions. The reaction can include
flushing, nausea, vomiting, and potentially life-threatening cardiovascular effects.
, 4. A client with Antisocial Personality Disorder is being treated in a group setting. Which of
the following traits should the nurse expect to observe?
A. Lack of empathy and disregard for the rights of others.
B. Social inhibition and feelings of inadequacy.
C. Excessive emotionality and attention-seeking behavior.
D. Magical thinking and odd perceptual distortions.
Correct Answer: A
Rationale: Antisocial Personality Disorder is characterized by a persistent pattern of
ignoring social norms and violating the rights of others. These clients often lack remorse
for their actions and can be highly manipulative to achieve their own goals. The nurse
should focus on setting clear boundaries and consequences for inappropriate behavior
within the therapeutic environment.
5. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
findings indicates the client is developing Delirium Tremens (DTs)?
A. Bradycardia and somnolence.
B. Hallucinations, hypertension, and tremors.
C. Hypotension and decreased deep tendon reflexes.
D. Hypoglycemia and dry mucous membranes.
Correct Answer: B
