NUR 208/NUR208 Exam 3 V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. Which nursing intervention is most appropriate?
A. Allow the client to choose which nurse they want to work with.
B. Hold a staff meeting to ensure a consistent approach by all team members.
C. Ignore the behavior to prevent reinforcing it.
D. Provide the client with extra attention to build trust.
Correct Answer: B
Explanation: Splitting involves the client seeing staff as all good or all bad, which can cause
conflict among the team. A consistent approach prevents the client from playing staff
against each other. It is essential for the nursing team to maintain firm boundaries and
open communication to provide effective care.
2. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering to prevent delirium tremens?
A. Disulfiram
B. Methadone
C. Fluoxetine
D. Chlordiazepoxide
,Correct Answer: D
Explanation: Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal
symptoms by providing cross-tolerance. It helps prevent seizures and progression to
delirium tremens during the acute phase of detox. The nurse must monitor vital signs and
sedation levels frequently while this medication is being administered.
3. A nurse is assessing a client with Anorexia Nervosa. Which physical finding is most
consistent with this diagnosis?
A. Hypertension
B. Tachycardia
C. Lanugo
D. Hyperkalemia
Correct Answer: C
Explanation: Lanugo is the growth of fine, downy hair on the body as a compensatory
mechanism for heat loss in severely underweight patients. Clients with anorexia often
exhibit bradycardia and hypotension rather than hypertension or tachycardia. These
physical manifestations reflect the body’s attempt to conserve energy during starvation.
4. A 10-year-old child is diagnosed with ADHD. The nurse is teaching the parents about
Methylphenidate. What should be included in the teaching?
A. Administer the medication right before bedtime.
B. Monitor the child’s weight and height regularly.
, C. Expect the child to have an increased appetite.
D. This medication will likely cause significant sedation.
Correct Answer: B
Explanation: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation. Parents must monitor growth milestones to ensure
the child is developing appropriately while on the medication. It is usually administered in
the morning to avoid insomnia at night.
5. A client with Antisocial Personality Disorder is being treated in a group setting. Which
behavior is the nurse most likely to observe?
A. Excessive emotionality and attention seeking.
B. Lack of remorse for hurting others.
C. Social withdrawal and fear of rejection.
D. Submissive and clinging behavior.
Correct Answer: B
Explanation: Antisocial Personality Disorder is characterized by a disregard for the rights
of others and a lack of empathy or remorse. These individuals often manipulate others for
personal gain and may have a history of legal issues. The nurse must maintain firm limits
and avoid being manipulated by the client’s charm.
Nursing Q&A with Rationale | Fortis College
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. Which nursing intervention is most appropriate?
A. Allow the client to choose which nurse they want to work with.
B. Hold a staff meeting to ensure a consistent approach by all team members.
C. Ignore the behavior to prevent reinforcing it.
D. Provide the client with extra attention to build trust.
Correct Answer: B
Explanation: Splitting involves the client seeing staff as all good or all bad, which can cause
conflict among the team. A consistent approach prevents the client from playing staff
against each other. It is essential for the nursing team to maintain firm boundaries and
open communication to provide effective care.
2. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering to prevent delirium tremens?
A. Disulfiram
B. Methadone
C. Fluoxetine
D. Chlordiazepoxide
,Correct Answer: D
Explanation: Chlordiazepoxide is a benzodiazepine used to manage alcohol withdrawal
symptoms by providing cross-tolerance. It helps prevent seizures and progression to
delirium tremens during the acute phase of detox. The nurse must monitor vital signs and
sedation levels frequently while this medication is being administered.
3. A nurse is assessing a client with Anorexia Nervosa. Which physical finding is most
consistent with this diagnosis?
A. Hypertension
B. Tachycardia
C. Lanugo
D. Hyperkalemia
Correct Answer: C
Explanation: Lanugo is the growth of fine, downy hair on the body as a compensatory
mechanism for heat loss in severely underweight patients. Clients with anorexia often
exhibit bradycardia and hypotension rather than hypertension or tachycardia. These
physical manifestations reflect the body’s attempt to conserve energy during starvation.
4. A 10-year-old child is diagnosed with ADHD. The nurse is teaching the parents about
Methylphenidate. What should be included in the teaching?
A. Administer the medication right before bedtime.
B. Monitor the child’s weight and height regularly.
, C. Expect the child to have an increased appetite.
D. This medication will likely cause significant sedation.
Correct Answer: B
Explanation: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation. Parents must monitor growth milestones to ensure
the child is developing appropriately while on the medication. It is usually administered in
the morning to avoid insomnia at night.
5. A client with Antisocial Personality Disorder is being treated in a group setting. Which
behavior is the nurse most likely to observe?
A. Excessive emotionality and attention seeking.
B. Lack of remorse for hurting others.
C. Social withdrawal and fear of rejection.
D. Submissive and clinging behavior.
Correct Answer: B
Explanation: Antisocial Personality Disorder is characterized by a disregard for the rights
of others and a lack of empathy or remorse. These individuals often manipulate others for
personal gain and may have a history of legal issues. The nurse must maintain firm limits
and avoid being manipulated by the client’s charm.
