PNR 200/PNR200 Exam 4 V1 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who is using
‘splitting’ behavior. Which nursing intervention is most appropriate?
A. Allowing the client to choose their primary nurse for the shift.
B. Assigning different nurses each day to prevent attachment.
C. Ensuring all staff maintain consistent limits and communication.
D. Engaging in long discussions about the client’s feelings toward staff.
Correct Answer: C
Explanation: Splitting is a defense mechanism where the client views individuals as all
good or all bad. By maintaining consistent limits, the staff prevents the client from playing
one person against another. This approach provides a stable and predictable environment
which is essential for therapeutic progress.
2. Which clinical manifestation should a nurse expect to see in a client experiencing Alcohol
Withdrawal Delirium?
A. Hypotension and bradycardia
B. Severe hypertension and hallucinations
C. Increased appetite and hypersomnia
D. Depressed mood and motor retardation
,Correct Answer: B
Explanation: Alcohol withdrawal delirium is a medical emergency that typically occurs 2
to 3 days after the last drink. It is characterized by severe autonomic hyperactivity,
including tachycardia, hypertension, and fever. Clients often experience vivid visual or
tactile hallucinations and extreme agitation.
3. A client with Antisocial Personality Disorder is being aggressive toward others in the unit.
What is the priority nursing action?
A. Set clear, firm limits on behavior and consequences.
B. Ask the client why they feel the need to be aggressive.
C. Explain how their behavior affects the other clients.
D. Provide a private room so the client can be alone.
Correct Answer: A
Explanation: Clients with Antisocial Personality Disorder often disregard the rights of
others and lack remorse. Setting firm limits on unacceptable behavior is the primary
intervention to maintain safety and structure. It is important that consequences are applied
consistently by the entire treatment team.
4. The nurse is educating a client about Disulfiram (Antabuse). Which statement by the client
indicates a need for further teaching?
A. I will avoid drinking wine or beer while taking this.
B. I need to check labels on cough syrups and mouthwashes.
, C. I can use alcohol-based hand sanitizer as long as I don’t drink it.
D. The effects of this drug can last for up to two weeks after I stop.
Correct Answer: C
Explanation: Disulfiram causes a severe reaction even with topical exposure to alcohol in
some sensitive individuals. Clients must be taught to avoid all forms of alcohol, including
hidden sources in foods and toiletries. The reaction involves flushing, nausea, and
potentially dangerous cardiovascular effects.
5. A client is admitted for opioid overdose. Which medication should the nurse have available
for immediate administration?
A. Methadone
B. Diazepam
C. Buprenorphine
D. Naloxone
Correct Answer: D
Explanation: Naloxone is an opioid antagonist used to rapidly reverse respiratory
depression caused by opioid toxicity. It competes with opioids for receptor sites in the
brain to restore normal breathing. Because it has a short half-life, the nurse must monitor
for the return of overdose symptoms.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who is using
‘splitting’ behavior. Which nursing intervention is most appropriate?
A. Allowing the client to choose their primary nurse for the shift.
B. Assigning different nurses each day to prevent attachment.
C. Ensuring all staff maintain consistent limits and communication.
D. Engaging in long discussions about the client’s feelings toward staff.
Correct Answer: C
Explanation: Splitting is a defense mechanism where the client views individuals as all
good or all bad. By maintaining consistent limits, the staff prevents the client from playing
one person against another. This approach provides a stable and predictable environment
which is essential for therapeutic progress.
2. Which clinical manifestation should a nurse expect to see in a client experiencing Alcohol
Withdrawal Delirium?
A. Hypotension and bradycardia
B. Severe hypertension and hallucinations
C. Increased appetite and hypersomnia
D. Depressed mood and motor retardation
,Correct Answer: B
Explanation: Alcohol withdrawal delirium is a medical emergency that typically occurs 2
to 3 days after the last drink. It is characterized by severe autonomic hyperactivity,
including tachycardia, hypertension, and fever. Clients often experience vivid visual or
tactile hallucinations and extreme agitation.
3. A client with Antisocial Personality Disorder is being aggressive toward others in the unit.
What is the priority nursing action?
A. Set clear, firm limits on behavior and consequences.
B. Ask the client why they feel the need to be aggressive.
C. Explain how their behavior affects the other clients.
D. Provide a private room so the client can be alone.
Correct Answer: A
Explanation: Clients with Antisocial Personality Disorder often disregard the rights of
others and lack remorse. Setting firm limits on unacceptable behavior is the primary
intervention to maintain safety and structure. It is important that consequences are applied
consistently by the entire treatment team.
4. The nurse is educating a client about Disulfiram (Antabuse). Which statement by the client
indicates a need for further teaching?
A. I will avoid drinking wine or beer while taking this.
B. I need to check labels on cough syrups and mouthwashes.
, C. I can use alcohol-based hand sanitizer as long as I don’t drink it.
D. The effects of this drug can last for up to two weeks after I stop.
Correct Answer: C
Explanation: Disulfiram causes a severe reaction even with topical exposure to alcohol in
some sensitive individuals. Clients must be taught to avoid all forms of alcohol, including
hidden sources in foods and toiletries. The reaction involves flushing, nausea, and
potentially dangerous cardiovascular effects.
5. A client is admitted for opioid overdose. Which medication should the nurse have available
for immediate administration?
A. Methadone
B. Diazepam
C. Buprenorphine
D. Naloxone
Correct Answer: D
Explanation: Naloxone is an opioid antagonist used to rapidly reverse respiratory
depression caused by opioid toxicity. It competes with opioids for receptor sites in the
brain to restore normal breathing. Because it has a short half-life, the nurse must monitor
for the return of overdose symptoms.
