NUR253 Exam 3 V2 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. Which nursing intervention is most effective in managing this defense mechanism?
A. Allow the client to choose their own primary nurse each shift.
B. Assign a different nurse each day to provide variety.
C. Avoid discussing the client’s behavior with other staff members.
D. Hold regular staff meetings to ensure a consistent approach.
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as all good or all bad. Frequent staff communication is
essential to prevent manipulation and ensure a unified treatment plan. Maintaining
consistency among all team members minimizes the client’s ability to create conflict within
the staff.
2. A client is admitted for alcohol detoxification. Which of the following medications should
the nurse anticipate administering to prevent the onset of delirium tremens?
A. Chlordiazepoxide
B. Naloxone
,C. Fluoxetine
D. Methadone
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal
symptoms by providing a cross-tolerant effect to alcohol. It helps prevent seizures and
progression to delirium tremens, which is a life-threatening emergency. The nurse must
monitor the client closely for respiratory depression and over-sedation during
administration.
3. The nurse is assessing a client using the CAGE questionnaire. Which question is associated
with the ‘E’ in CAGE?
A. Have you ever felt you should cut down on your drinking?
B. Have you ever felt bad or guilty about your drinking?
C. Have people annoyed you by criticizing your drinking?
D. Have you ever had a drink first thing in the morning to steady your nerves?
Answer: D
Rationale: The ‘E’ in CAGE stands for Eye-opener, referring to a drink taken early in the
day to relieve withdrawal symptoms. This questionnaire is a validated screening tool for
alcohol use disorder. A positive response to two or more questions suggests a high
probability of alcohol dependence.
, 4. A client with Antisocial Personality Disorder is being treated in a psychiatric unit. Which
behavior is the nurse most likely to observe?
A. Excessive emotionality and attention-seeking behavior.
B. Pervasive distrust and suspiciousness of others.
C. Extreme social inhibition due to feelings of inadequacy.
D. Lack of remorse for hurting others and manipulation.
Answer: D
Rationale: Clients with Antisocial Personality Disorder typically disregard the rights of
others and show a profound lack of empathy or remorse. Manipulation is a hallmark trait
used to achieve personal goals or gain power. Nursing interventions should focus on
setting clear limits and holding the client accountable for their actions.
5. Which assessment finding is most indicative of an opioid overdose?
A. Pinpoint pupils and respiratory depression.
B. Dilated pupils and agitation.
C. Tachycardia and hypertension.
D. Hyperreflexia and tremors.
Answer: A
Rationale: Opioids are central nervous system depressants that cause significant
respiratory suppression and miosis (pinpoint pupils). Assessment of the client’s airway and
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. Which nursing intervention is most effective in managing this defense mechanism?
A. Allow the client to choose their own primary nurse each shift.
B. Assign a different nurse each day to provide variety.
C. Avoid discussing the client’s behavior with other staff members.
D. Hold regular staff meetings to ensure a consistent approach.
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as all good or all bad. Frequent staff communication is
essential to prevent manipulation and ensure a unified treatment plan. Maintaining
consistency among all team members minimizes the client’s ability to create conflict within
the staff.
2. A client is admitted for alcohol detoxification. Which of the following medications should
the nurse anticipate administering to prevent the onset of delirium tremens?
A. Chlordiazepoxide
B. Naloxone
,C. Fluoxetine
D. Methadone
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal
symptoms by providing a cross-tolerant effect to alcohol. It helps prevent seizures and
progression to delirium tremens, which is a life-threatening emergency. The nurse must
monitor the client closely for respiratory depression and over-sedation during
administration.
3. The nurse is assessing a client using the CAGE questionnaire. Which question is associated
with the ‘E’ in CAGE?
A. Have you ever felt you should cut down on your drinking?
B. Have you ever felt bad or guilty about your drinking?
C. Have people annoyed you by criticizing your drinking?
D. Have you ever had a drink first thing in the morning to steady your nerves?
Answer: D
Rationale: The ‘E’ in CAGE stands for Eye-opener, referring to a drink taken early in the
day to relieve withdrawal symptoms. This questionnaire is a validated screening tool for
alcohol use disorder. A positive response to two or more questions suggests a high
probability of alcohol dependence.
, 4. A client with Antisocial Personality Disorder is being treated in a psychiatric unit. Which
behavior is the nurse most likely to observe?
A. Excessive emotionality and attention-seeking behavior.
B. Pervasive distrust and suspiciousness of others.
C. Extreme social inhibition due to feelings of inadequacy.
D. Lack of remorse for hurting others and manipulation.
Answer: D
Rationale: Clients with Antisocial Personality Disorder typically disregard the rights of
others and show a profound lack of empathy or remorse. Manipulation is a hallmark trait
used to achieve personal goals or gain power. Nursing interventions should focus on
setting clear limits and holding the client accountable for their actions.
5. Which assessment finding is most indicative of an opioid overdose?
A. Pinpoint pupils and respiratory depression.
B. Dilated pupils and agitation.
C. Tachycardia and hypertension.
D. Hyperreflexia and tremors.
Answer: A
Rationale: Opioids are central nervous system depressants that cause significant
respiratory suppression and miosis (pinpoint pupils). Assessment of the client’s airway and
