NSG221/NSG 221 Exam 4 V3 | Mental
Health Nursing Q&A with Rationale |
Herzing University
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ when talking to staff. Which nursing action is most appropriate?
A. Hold a staff meeting to ensure a consistent approach and unified plan of care.
B. Allow the client to choose which nurse they prefer to work with during the shift.
C. Ignore the behavior as it is a common attention-seeking mechanism.
D. Provide the client with extra one-on-one time to build a trusting relationship.
Correct Answer: A
Rationale: Splitting is a defense mechanism where the client views people as all good or all
bad, which can cause conflict among staff members. By holding a staff meeting, the team
ensures a consistent approach to boundaries and care, preventing the client from
manipulating staff roles. Consistency is the most critical intervention for clients with
Cluster B personality disorders to maintain a therapeutic environment.
2. A client is admitted to the emergency department with suspected opioid overdose. Which
clinical manifestation should the nurse anticipate?
A. Respiratory depression and pinpoint pupils.
B. Tachycardia and dilated pupils.
,C. Hypertension and hyperreflexia.
D. Increased bowel sounds and diaphoresis.
Correct Answer: A
Rationale: Opioid toxicity typically presents with the ‘opioid triad’ of coma, respiratory
depression, and pinpoint pupils (miosis). Monitoring for a decrease in the respiratory rate
is the priority as it can lead to respiratory arrest. The nurse should be prepared to
administer Naloxone, which is the specific antagonist for opioid-induced CNS depression.
3. Which of the following is a key differentiating factor between Delirium and Dementia?
A. Dementia has a rapid, acute onset while Delirium is chronic.
B. Delirium is characterized by a fluctuating level of consciousness, whereas Dementia is
stable.
C. Delirium only occurs in elderly patients, while Dementia occurs at any age.
D. Memory loss is only present in Dementia and not in Delirium.
Correct Answer: B
Rationale: Delirium is an acute clinical syndrome characterized by a disturbance in
consciousness and a change in cognition that develops over a short period. Unlike
Dementia, which involves a progressive and stable decline in cognitive function, Delirium
involves fluctuations in alertness throughout the day. Identifying the underlying cause of
delirium is vital because it is often reversible once the medical trigger is treated.
, 4. A nurse is assessing a client with Anorexia Nervosa. Which physical finding would support
this diagnosis?
A. Parotid gland swelling and dental caries.
B. The presence of lanugo and bradycardia.
C. Tachycardia and hypertension.
D. Heavy menstrual cycles and oily skin.
Correct Answer: B
Rationale: Lanugo, which is fine, downy hair, is a compensatory mechanism the body uses
to provide insulation due to the loss of subcutaneous fat in anorexia. Bradycardia and
hypotension are common cardiovascular responses to the body’s starved state. Other
symptoms may include amenorrhea and a core body temperature below normal limits.
5. A client with Antisocial Personality Disorder is being aggressive toward another peer. What
is the priority nursing intervention?
A. Ask the client to explain why they are angry at their peer.
B. Encourage the client to express their feelings in a group setting.
C. Set clear, firm limits on behavior and consequences.
D. Administer a sedative immediately to prevent further escalation.
Correct Answer: C
Health Nursing Q&A with Rationale |
Herzing University
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ when talking to staff. Which nursing action is most appropriate?
A. Hold a staff meeting to ensure a consistent approach and unified plan of care.
B. Allow the client to choose which nurse they prefer to work with during the shift.
C. Ignore the behavior as it is a common attention-seeking mechanism.
D. Provide the client with extra one-on-one time to build a trusting relationship.
Correct Answer: A
Rationale: Splitting is a defense mechanism where the client views people as all good or all
bad, which can cause conflict among staff members. By holding a staff meeting, the team
ensures a consistent approach to boundaries and care, preventing the client from
manipulating staff roles. Consistency is the most critical intervention for clients with
Cluster B personality disorders to maintain a therapeutic environment.
2. A client is admitted to the emergency department with suspected opioid overdose. Which
clinical manifestation should the nurse anticipate?
A. Respiratory depression and pinpoint pupils.
B. Tachycardia and dilated pupils.
,C. Hypertension and hyperreflexia.
D. Increased bowel sounds and diaphoresis.
Correct Answer: A
Rationale: Opioid toxicity typically presents with the ‘opioid triad’ of coma, respiratory
depression, and pinpoint pupils (miosis). Monitoring for a decrease in the respiratory rate
is the priority as it can lead to respiratory arrest. The nurse should be prepared to
administer Naloxone, which is the specific antagonist for opioid-induced CNS depression.
3. Which of the following is a key differentiating factor between Delirium and Dementia?
A. Dementia has a rapid, acute onset while Delirium is chronic.
B. Delirium is characterized by a fluctuating level of consciousness, whereas Dementia is
stable.
C. Delirium only occurs in elderly patients, while Dementia occurs at any age.
D. Memory loss is only present in Dementia and not in Delirium.
Correct Answer: B
Rationale: Delirium is an acute clinical syndrome characterized by a disturbance in
consciousness and a change in cognition that develops over a short period. Unlike
Dementia, which involves a progressive and stable decline in cognitive function, Delirium
involves fluctuations in alertness throughout the day. Identifying the underlying cause of
delirium is vital because it is often reversible once the medical trigger is treated.
, 4. A nurse is assessing a client with Anorexia Nervosa. Which physical finding would support
this diagnosis?
A. Parotid gland swelling and dental caries.
B. The presence of lanugo and bradycardia.
C. Tachycardia and hypertension.
D. Heavy menstrual cycles and oily skin.
Correct Answer: B
Rationale: Lanugo, which is fine, downy hair, is a compensatory mechanism the body uses
to provide insulation due to the loss of subcutaneous fat in anorexia. Bradycardia and
hypotension are common cardiovascular responses to the body’s starved state. Other
symptoms may include amenorrhea and a core body temperature below normal limits.
5. A client with Antisocial Personality Disorder is being aggressive toward another peer. What
is the priority nursing intervention?
A. Ask the client to explain why they are angry at their peer.
B. Encourage the client to express their feelings in a group setting.
C. Set clear, firm limits on behavior and consequences.
D. Administer a sedative immediately to prevent further escalation.
Correct Answer: C
