NSG 322/NSG322 Exam 3 V3 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who is
‘splitting’ the staff. Which nursing action is most appropriate?
A. Assign a single staff member to provide all care for the client.
B. Allow the client to choose which nurse they prefer to work with.
C. Hold a staff meeting to ensure consistent limits and a unified approach.
D. Confront the client about their manipulative behavior immediately.
Answer: C
Rationale: Splitting is a primitive defense mechanism where the client views individuals as
either all good or all bad. To counteract this, the nursing staff must maintain open
communication and strict consistency in the care plan. Holding regular staff meetings
prevents the client from playing one staff member against another.
2. A client is admitted for alcohol detoxification. Which medication should the nurse expect
to administer to prevent Wernicke-Korsakoff syndrome?
A. Lorazepam
B. Disulfiram
C. Thiamine (Vitamin B1)
,D. Naloxone
Answer: C
Rationale: Wernicke-Korsakoff syndrome is a serious neurological condition caused by a
deficiency in thiamine, often seen in chronic alcoholics. Administering thiamine helps
protect the brain from permanent cognitive impairment and ataxia. It is a standard part of
the protocol for clients undergoing alcohol withdrawal in the clinical setting.
3. Which physical assessment finding is most characteristic of a client with Anorexia Nervosa?
A. Tachycardia and hypertension
B. Hyperkalemia and moist skin
C. Lanugo and bradycardia
D. Increased bone density
Answer: C
Rationale: Lanugo is the growth of fine, downy hair on the body as a physiological
response to preserve body heat in the absence of subcutaneous fat. Bradycardia occurs as
the heart muscle weakens and the metabolic rate slows down significantly. These findings
are critical indicators of the severity of malnutrition in Anorexia Nervosa.
4. A nurse is assessing a client for suspected opioid overdose. Which clinical manifestation
should the nurse prioritize?
A. Pinpoint pupils and respiratory depression
, B. Dilated pupils and agitation
C. Hyperreflexia and diarrhea
D. Seizures and hyperthermia
Answer: A
Rationale: Opioid toxicity typically presents with a ‘triad’ of symptoms: pinpoint pupils,
respiratory depression, and a depressed level of consciousness. The nurse must prioritize
airway and breathing because respiratory arrest is the leading cause of death in these
cases. Immediate administration of an opioid antagonist like Naloxone is usually indicated.
5. A client with Antisocial Personality Disorder is being treated in a behavioral health unit.
Which behavior is the nurse most likely to observe?
A. Excessive clinging and fear of abandonment
B. Perfectionism and preoccupation with details
C. Social withdrawal due to extreme shyness
D. Lack of remorse for hurting others and manipulation
Answer: D
Rationale: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others and a lack of empathy. These clients often engage in
deceitful or manipulative behaviors for personal gain or pleasure. They rarely feel guilt or
remorse for the consequences of their actions on others.
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who is
‘splitting’ the staff. Which nursing action is most appropriate?
A. Assign a single staff member to provide all care for the client.
B. Allow the client to choose which nurse they prefer to work with.
C. Hold a staff meeting to ensure consistent limits and a unified approach.
D. Confront the client about their manipulative behavior immediately.
Answer: C
Rationale: Splitting is a primitive defense mechanism where the client views individuals as
either all good or all bad. To counteract this, the nursing staff must maintain open
communication and strict consistency in the care plan. Holding regular staff meetings
prevents the client from playing one staff member against another.
2. A client is admitted for alcohol detoxification. Which medication should the nurse expect
to administer to prevent Wernicke-Korsakoff syndrome?
A. Lorazepam
B. Disulfiram
C. Thiamine (Vitamin B1)
,D. Naloxone
Answer: C
Rationale: Wernicke-Korsakoff syndrome is a serious neurological condition caused by a
deficiency in thiamine, often seen in chronic alcoholics. Administering thiamine helps
protect the brain from permanent cognitive impairment and ataxia. It is a standard part of
the protocol for clients undergoing alcohol withdrawal in the clinical setting.
3. Which physical assessment finding is most characteristic of a client with Anorexia Nervosa?
A. Tachycardia and hypertension
B. Hyperkalemia and moist skin
C. Lanugo and bradycardia
D. Increased bone density
Answer: C
Rationale: Lanugo is the growth of fine, downy hair on the body as a physiological
response to preserve body heat in the absence of subcutaneous fat. Bradycardia occurs as
the heart muscle weakens and the metabolic rate slows down significantly. These findings
are critical indicators of the severity of malnutrition in Anorexia Nervosa.
4. A nurse is assessing a client for suspected opioid overdose. Which clinical manifestation
should the nurse prioritize?
A. Pinpoint pupils and respiratory depression
, B. Dilated pupils and agitation
C. Hyperreflexia and diarrhea
D. Seizures and hyperthermia
Answer: A
Rationale: Opioid toxicity typically presents with a ‘triad’ of symptoms: pinpoint pupils,
respiratory depression, and a depressed level of consciousness. The nurse must prioritize
airway and breathing because respiratory arrest is the leading cause of death in these
cases. Immediate administration of an opioid antagonist like Naloxone is usually indicated.
5. A client with Antisocial Personality Disorder is being treated in a behavioral health unit.
Which behavior is the nurse most likely to observe?
A. Excessive clinging and fear of abandonment
B. Perfectionism and preoccupation with details
C. Social withdrawal due to extreme shyness
D. Lack of remorse for hurting others and manipulation
Answer: D
Rationale: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others and a lack of empathy. These clients often engage in
deceitful or manipulative behaviors for personal gain or pleasure. They rarely feel guilt or
remorse for the consequences of their actions on others.
