NUR253 Exam 3 V2 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
medications should the nurse expect to administer to prevent seizures?
A. Lorazepam
B. Methadone
C. Disulfiram
D. Naltrexone
Answer: A
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing alcohol
withdrawal symptoms and preventing seizures. They work by enhancing GABA activity to
calm the central nervous system. This intervention is critical during the first 48 to 72 hours
of cessation.
2. A client with Borderline Personality Disorder (BPD) is using ‘splitting’ by praising one nurse
and criticizing another. What is the most appropriate nursing intervention?
A. Confront the client about their behavior immediately.
B. Hold a staff meeting to ensure a consistent approach.
C. Agree with the client’s assessment of the other nurse.
,D. Avoid the client until they can act professionally.
Answer: B
Rationale: Consistency among the treatment team is vital to prevent the client from
playing staff members against each other. Splitting is a primitive defense mechanism where
individuals see others as all good or all bad. Frequent staff communication ensures that the
care plan remains cohesive and boundaries are maintained.
3. Which assessment tool is specifically designed to evaluate the severity of alcohol
withdrawal symptoms?
A. CAGE questionnaire
B. MMSE
C. CIWA-Ar
D. PHQ-9
Answer: C
Rationale: The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is used to
monitor the progression of withdrawal and determine medication needs. It assesses
categories such as tremors, nausea, and anxiety to provide a numerical score. This allows
the nursing staff to provide evidence-based, objective care.
4. A nurse is educating a client about Disulfiram therapy. Which of the following instructions
is the most important to include?
A. Avoid all products containing alcohol, including mouthwash and vanilla extract.
, B. Take the medication only when you feel an urge to drink.
C. You can safely consume non-alcoholic beer while on this medication.
D. The medication will reduce your cravings for opioids as well.
Answer: A
Rationale: Disulfiram causes a severe physical reaction if any alcohol is ingested, including
hidden sources like cough syrup or topical products. The reaction involves flushing, nausea,
and tachycardia which can be life-threatening. Education must emphasize total abstinence
from all ethanol-containing products.
5. A client is admitted for an opioid overdose. Which clinical finding should the nurse
prioritize?
A. Respiratory rate of 6/min
B. Tachycardia
C. Dilated pupils
D. Hyperreflexia
Answer: A
Rationale: Opioid overdose is characterized by the ‘opioid triad’ of respiratory depression,
pinpoint pupils, and coma. A respiratory rate of 6/min is a life-threatening emergency
requiring immediate intervention with Naloxone. Maintaining the airway and ventilation is
the highest priority in these cases.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
medications should the nurse expect to administer to prevent seizures?
A. Lorazepam
B. Methadone
C. Disulfiram
D. Naltrexone
Answer: A
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing alcohol
withdrawal symptoms and preventing seizures. They work by enhancing GABA activity to
calm the central nervous system. This intervention is critical during the first 48 to 72 hours
of cessation.
2. A client with Borderline Personality Disorder (BPD) is using ‘splitting’ by praising one nurse
and criticizing another. What is the most appropriate nursing intervention?
A. Confront the client about their behavior immediately.
B. Hold a staff meeting to ensure a consistent approach.
C. Agree with the client’s assessment of the other nurse.
,D. Avoid the client until they can act professionally.
Answer: B
Rationale: Consistency among the treatment team is vital to prevent the client from
playing staff members against each other. Splitting is a primitive defense mechanism where
individuals see others as all good or all bad. Frequent staff communication ensures that the
care plan remains cohesive and boundaries are maintained.
3. Which assessment tool is specifically designed to evaluate the severity of alcohol
withdrawal symptoms?
A. CAGE questionnaire
B. MMSE
C. CIWA-Ar
D. PHQ-9
Answer: C
Rationale: The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is used to
monitor the progression of withdrawal and determine medication needs. It assesses
categories such as tremors, nausea, and anxiety to provide a numerical score. This allows
the nursing staff to provide evidence-based, objective care.
4. A nurse is educating a client about Disulfiram therapy. Which of the following instructions
is the most important to include?
A. Avoid all products containing alcohol, including mouthwash and vanilla extract.
, B. Take the medication only when you feel an urge to drink.
C. You can safely consume non-alcoholic beer while on this medication.
D. The medication will reduce your cravings for opioids as well.
Answer: A
Rationale: Disulfiram causes a severe physical reaction if any alcohol is ingested, including
hidden sources like cough syrup or topical products. The reaction involves flushing, nausea,
and tachycardia which can be life-threatening. Education must emphasize total abstinence
from all ethanol-containing products.
5. A client is admitted for an opioid overdose. Which clinical finding should the nurse
prioritize?
A. Respiratory rate of 6/min
B. Tachycardia
C. Dilated pupils
D. Hyperreflexia
Answer: A
Rationale: Opioid overdose is characterized by the ‘opioid triad’ of respiratory depression,
pinpoint pupils, and coma. A respiratory rate of 6/min is a life-threatening emergency
requiring immediate intervention with Naloxone. Maintaining the airway and ventilation is
the highest priority in these cases.
