NSG 322/NSG322 Exam 4 V1 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client diagnosed with Delirium. Which of the following is the priority
nursing intervention?
A. Maintaining a safe environment to prevent injury.
B. Providing a high-stimulation environment to keep the client alert.
C. Educating the family on the long-term progression of the disease.
D. Administering heavy sedation to manage agitation.
Answer: A
Rationale: Safety is the absolute priority for a client with delirium due to their confusion
and potential for impulsive behavior or falls. The nurse should ensure the room is free of
hazards and provide appropriate supervision. Delirium is often acute and reversible, unlike
dementia, requiring focused physiological and safety management.
2. A client with Alzheimer’s disease is experiencing agnosia. Which behavior should the nurse
expect to observe?
A. The client is unable to recognize familiar objects like a toothbrush.
B. The client is unable to find the correct words to speak.
C. The client is experiencing a decline in motor function.
,D. The client is repeating words spoken by others.
Answer: A
Rationale: Agnosia is the failure to recognize or identify objects despite intact sensory
function. This symptom is common in the middle to late stages of Alzheimer’s disease and
can lead to significant frustration. Nurses must provide labels or demonstrations to help
the client navigate their environment safely.
3. Which medication is an NMDA receptor antagonist used to treat moderate to severe
Alzheimer’s disease?
A. Donepezil
B. Rivastigmine
C. Galantamine
D. Memantine
Answer: D
Rationale: Memantine (Namenda) is specifically classified as an NMDA receptor
antagonist, which helps regulate glutamate activity in the brain. Unlike cholinesterase
inhibitors, it is typically reserved for more advanced stages of the disease. It can be used
alone or in combination with medications like Donepezil for synergistic effects.
4. A client with Borderline Personality Disorder is ‘splitting’ staff members. How should the
nursing team respond?
A. Hold a staff meeting to ensure a consistent approach to the client’s care.
, B. Allow the client to choose which nurse they want to work with.
C. Confront the client aggressively about their manipulative behavior.
D. Limit the client’s social interactions with all other patients.
Answer: A
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad, which can cause conflict among the healthcare team. Consistency and open
communication among staff members are vital to prevent the client from playing one
person against another. A unified care plan helps maintain professional boundaries and
therapeutic goals.
5. A nurse is assessing a client for Alcohol Withdrawal Syndrome. Which of the following
symptoms would indicate a medical emergency?
A. Mild tremors and anxiety.
B. Diaphoresis and nausea.
C. Fatigue and increased appetite.
D. Tachycardia, hypertension, and hallucinations.
Answer: D
Rationale: Tachycardia, hypertension, and hallucinations are indicative of Delirium
Tremens (DTs), which is a life-threatening complication of alcohol withdrawal. These
symptoms typically appear 48 to 72 hours after the last drink and require immediate
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client diagnosed with Delirium. Which of the following is the priority
nursing intervention?
A. Maintaining a safe environment to prevent injury.
B. Providing a high-stimulation environment to keep the client alert.
C. Educating the family on the long-term progression of the disease.
D. Administering heavy sedation to manage agitation.
Answer: A
Rationale: Safety is the absolute priority for a client with delirium due to their confusion
and potential for impulsive behavior or falls. The nurse should ensure the room is free of
hazards and provide appropriate supervision. Delirium is often acute and reversible, unlike
dementia, requiring focused physiological and safety management.
2. A client with Alzheimer’s disease is experiencing agnosia. Which behavior should the nurse
expect to observe?
A. The client is unable to recognize familiar objects like a toothbrush.
B. The client is unable to find the correct words to speak.
C. The client is experiencing a decline in motor function.
,D. The client is repeating words spoken by others.
Answer: A
Rationale: Agnosia is the failure to recognize or identify objects despite intact sensory
function. This symptom is common in the middle to late stages of Alzheimer’s disease and
can lead to significant frustration. Nurses must provide labels or demonstrations to help
the client navigate their environment safely.
3. Which medication is an NMDA receptor antagonist used to treat moderate to severe
Alzheimer’s disease?
A. Donepezil
B. Rivastigmine
C. Galantamine
D. Memantine
Answer: D
Rationale: Memantine (Namenda) is specifically classified as an NMDA receptor
antagonist, which helps regulate glutamate activity in the brain. Unlike cholinesterase
inhibitors, it is typically reserved for more advanced stages of the disease. It can be used
alone or in combination with medications like Donepezil for synergistic effects.
4. A client with Borderline Personality Disorder is ‘splitting’ staff members. How should the
nursing team respond?
A. Hold a staff meeting to ensure a consistent approach to the client’s care.
, B. Allow the client to choose which nurse they want to work with.
C. Confront the client aggressively about their manipulative behavior.
D. Limit the client’s social interactions with all other patients.
Answer: A
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad, which can cause conflict among the healthcare team. Consistency and open
communication among staff members are vital to prevent the client from playing one
person against another. A unified care plan helps maintain professional boundaries and
therapeutic goals.
5. A nurse is assessing a client for Alcohol Withdrawal Syndrome. Which of the following
symptoms would indicate a medical emergency?
A. Mild tremors and anxiety.
B. Diaphoresis and nausea.
C. Fatigue and increased appetite.
D. Tachycardia, hypertension, and hallucinations.
Answer: D
Rationale: Tachycardia, hypertension, and hallucinations are indicative of Delirium
Tremens (DTs), which is a life-threatening complication of alcohol withdrawal. These
symptoms typically appear 48 to 72 hours after the last drink and require immediate
