NUR2459/NUR 2459 Exam 4 V3 | Mental
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder (BPD) who is using
splitting to manipulate the staff. What is the most appropriate nursing intervention?
A. Hold a staff meeting to ensure consistent limits and communication.
B. Allow the client to choose which nurse provides care.
C. Encourage the client to discuss feelings with several different staff members.
D. Provide the client with special privileges to avoid conflict.
Answer: A
Rationale: Splitting involves the client seeing staff as either all good or all bad, which can
cause conflict within the treatment team. Consistent limit-setting and frequent staff
communication are essential to prevent manipulation. This approach ensures that the
entire team provides a unified front and prevents the client from playing staff members
against each other.
2. Which assessment finding should a nurse prioritize for a client admitted with Anorexia
Nervosa?
A. Lanugo on the back and arms.
B. Bradycardia and hypotension.
,C. Amenorrhea for six months.
D. Preoccupation with food recipes.
Answer: B
Rationale: Bradycardia and hypotension are critical physiological indicators of
cardiovascular instability in clients with severe malnutrition. While lanugo and
amenorrhea are common findings, they are not immediately life-threatening. The nurse
must prioritize vital signs to prevent cardiac arrest or sudden death associated with
starvation.
3. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse expect to administer?
A. Lorazepam
B. Naloxone
C. Disulfiram
D. Methadone
Answer: A
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help prevent progression to seizures and delirium
tremens by stabilizing the central nervous system. Disulfiram is used for maintenance of
sobriety, not acute withdrawal management.
, 4. A client with Alzheimer’s disease frequently wanders the halls at night. Which intervention
is most appropriate for safety?
A. Apply soft wrist restraints during sleep hours.
B. Install alarm systems on exit doors and provide a supervised walking area.
C. Administer a sedative to ensure the client stays in bed.
D. Keep the room lights completely off to encourage sleep.
Answer: B
Rationale: Safety for wandering clients is best managed through environmental
modifications rather than physical or chemical restraints. Door alarms provide an alert if
the client attempts to leave a safe area, and supervised walking allows for activity without
risk. Restraints can increase agitation and injury risk in clients with dementia.
5. A client with Antisocial Personality Disorder is being disruptive in a group therapy session.
Which response by the nurse is most therapeutic?
A. Why are you acting this way today?
B. I will give you a PRN medication if you do not stop.
C. If you continue this behavior, you will have to leave the group.
D. The other clients are upset by your behavior.
Answer: C
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder (BPD) who is using
splitting to manipulate the staff. What is the most appropriate nursing intervention?
A. Hold a staff meeting to ensure consistent limits and communication.
B. Allow the client to choose which nurse provides care.
C. Encourage the client to discuss feelings with several different staff members.
D. Provide the client with special privileges to avoid conflict.
Answer: A
Rationale: Splitting involves the client seeing staff as either all good or all bad, which can
cause conflict within the treatment team. Consistent limit-setting and frequent staff
communication are essential to prevent manipulation. This approach ensures that the
entire team provides a unified front and prevents the client from playing staff members
against each other.
2. Which assessment finding should a nurse prioritize for a client admitted with Anorexia
Nervosa?
A. Lanugo on the back and arms.
B. Bradycardia and hypotension.
,C. Amenorrhea for six months.
D. Preoccupation with food recipes.
Answer: B
Rationale: Bradycardia and hypotension are critical physiological indicators of
cardiovascular instability in clients with severe malnutrition. While lanugo and
amenorrhea are common findings, they are not immediately life-threatening. The nurse
must prioritize vital signs to prevent cardiac arrest or sudden death associated with
starvation.
3. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse expect to administer?
A. Lorazepam
B. Naloxone
C. Disulfiram
D. Methadone
Answer: A
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help prevent progression to seizures and delirium
tremens by stabilizing the central nervous system. Disulfiram is used for maintenance of
sobriety, not acute withdrawal management.
, 4. A client with Alzheimer’s disease frequently wanders the halls at night. Which intervention
is most appropriate for safety?
A. Apply soft wrist restraints during sleep hours.
B. Install alarm systems on exit doors and provide a supervised walking area.
C. Administer a sedative to ensure the client stays in bed.
D. Keep the room lights completely off to encourage sleep.
Answer: B
Rationale: Safety for wandering clients is best managed through environmental
modifications rather than physical or chemical restraints. Door alarms provide an alert if
the client attempts to leave a safe area, and supervised walking allows for activity without
risk. Restraints can increase agitation and injury risk in clients with dementia.
5. A client with Antisocial Personality Disorder is being disruptive in a group therapy session.
Which response by the nurse is most therapeutic?
A. Why are you acting this way today?
B. I will give you a PRN medication if you do not stop.
C. If you continue this behavior, you will have to leave the group.
D. The other clients are upset by your behavior.
Answer: C
