NUR253 Exam 3 V3 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A patient is admitted for alcohol detoxification. Which of the following assessment findings
would the nurse identify as a sign of early alcohol withdrawal?
A. Severe hypotension and bradycardia
B. Visual hallucinations and seizures
C. Course tremors and diaphoresis
D. Extreme lethargy and somnolence
Answer: C
Rationale: Early alcohol withdrawal typically begins 6 to 12 hours after the last drink and
is characterized by tremors, tachycardia, and sweating. Monitoring for these symptoms is
crucial as they can progress to more severe stages if not treated. The nurse should use the
CIWA-Ar scale to quantify the severity of these symptoms and guide intervention.
2. When assessing a patient for suicide risk, which factor is considered the most significant
indicator of high lethality?
A. A history of generalized anxiety disorder
B. Strong religious beliefs against suicide
C. Occasional thoughts of wishing they were dead
,D. A specific plan with access to a highly lethal method
Answer: D
Rationale: A specific plan indicates a high level of intent and immediate risk to the patient.
Access to a lethal method, such as a firearm, significantly increases the likelihood of a
completed suicide. The nurse must prioritize safety and immediate observation when a
plan and means are present.
3. A patient with Borderline Personality Disorder (BPD) tells a nurse, ‘You are the only one
who cares about me; all the other nurses are mean.’ This is an example of:
A. Intellectualization
B. Reaction formation
C. Splitting
D. Sublimation
Answer: C
Rationale: Splitting is a common defense mechanism in BPD where individuals categorize
people as ‘all good’ or ‘all bad.’ This behavior can cause conflict among staff members and
disrupt the therapeutic environment. Nurses must maintain consistent communication and
firm boundaries to manage this dynamic effectively.
4. Which medication is commonly prescribed to assist with long-term maintenance of alcohol
abstinence by causing a severe physical reaction if alcohol is consumed?
A. Lorazepam
, B. Disulfiram
C. Naloxone
D. Methadone
Answer: B
Rationale: Disulfiram works by inhibiting the enzyme that breaks down acetaldehyde,
leading to symptoms like nausea, vomiting, and tachycardia if alcohol is ingested. It is used
as a deterrent therapy for patients motivated to maintain sobriety. Education must include
avoiding hidden sources of alcohol like mouthwash or vanilla extract.
5. In the context of family therapy, ‘triangulation’ occurs when:
A. Three family members work together to solve a conflict
B. The therapist meets with three generations of the family at once
C. A third person is pulled into a conflict between two others to decrease tension
D. Parents agree on a consistent discipline plan for their child
Answer: C
Rationale: Triangulation is a dysfunctional communication pattern where a dyad involves
a third person to stabilize their relationship. This prevents the original two individuals
from addressing the root cause of their conflict directly. Therapy aims to help family
members communicate more openly and resolve issues without involving others.
Health Nursing Exam Q&A | Galen College
of Nursing
1. A patient is admitted for alcohol detoxification. Which of the following assessment findings
would the nurse identify as a sign of early alcohol withdrawal?
A. Severe hypotension and bradycardia
B. Visual hallucinations and seizures
C. Course tremors and diaphoresis
D. Extreme lethargy and somnolence
Answer: C
Rationale: Early alcohol withdrawal typically begins 6 to 12 hours after the last drink and
is characterized by tremors, tachycardia, and sweating. Monitoring for these symptoms is
crucial as they can progress to more severe stages if not treated. The nurse should use the
CIWA-Ar scale to quantify the severity of these symptoms and guide intervention.
2. When assessing a patient for suicide risk, which factor is considered the most significant
indicator of high lethality?
A. A history of generalized anxiety disorder
B. Strong religious beliefs against suicide
C. Occasional thoughts of wishing they were dead
,D. A specific plan with access to a highly lethal method
Answer: D
Rationale: A specific plan indicates a high level of intent and immediate risk to the patient.
Access to a lethal method, such as a firearm, significantly increases the likelihood of a
completed suicide. The nurse must prioritize safety and immediate observation when a
plan and means are present.
3. A patient with Borderline Personality Disorder (BPD) tells a nurse, ‘You are the only one
who cares about me; all the other nurses are mean.’ This is an example of:
A. Intellectualization
B. Reaction formation
C. Splitting
D. Sublimation
Answer: C
Rationale: Splitting is a common defense mechanism in BPD where individuals categorize
people as ‘all good’ or ‘all bad.’ This behavior can cause conflict among staff members and
disrupt the therapeutic environment. Nurses must maintain consistent communication and
firm boundaries to manage this dynamic effectively.
4. Which medication is commonly prescribed to assist with long-term maintenance of alcohol
abstinence by causing a severe physical reaction if alcohol is consumed?
A. Lorazepam
, B. Disulfiram
C. Naloxone
D. Methadone
Answer: B
Rationale: Disulfiram works by inhibiting the enzyme that breaks down acetaldehyde,
leading to symptoms like nausea, vomiting, and tachycardia if alcohol is ingested. It is used
as a deterrent therapy for patients motivated to maintain sobriety. Education must include
avoiding hidden sources of alcohol like mouthwash or vanilla extract.
5. In the context of family therapy, ‘triangulation’ occurs when:
A. Three family members work together to solve a conflict
B. The therapist meets with three generations of the family at once
C. A third person is pulled into a conflict between two others to decrease tension
D. Parents agree on a consistent discipline plan for their child
Answer: C
Rationale: Triangulation is a dysfunctional communication pattern where a dyad involves
a third person to stabilize their relationship. This prevents the original two individuals
from addressing the root cause of their conflict directly. Therapy aims to help family
members communicate more openly and resolve issues without involving others.
