NUR 208/NUR208 Exam 2 V1 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A client is admitted to the psychiatric unit with a diagnosis of Obsessive-Compulsive
Disorder (OCD). The nurse observes the client performing repetitive hand-washing rituals.
Which nursing intervention is most appropriate during the initial phase of treatment?
A. Allow the client enough time to perform the ritual to decrease anxiety.
B. Interrupt the ritual to explain the physiological damage to the skin.
C. Request a physician’s order for physical restraints to stop the behavior.
D. Assign a staff member to sit with the client and prevent the hand-washing.
Correct Answer: A
Explanation: During the initial phase of OCD treatment, allowing the client to perform the
ritual is essential to prevent an overwhelming spike in anxiety. Restricting the ritual
abruptly without alternative coping mechanisms can lead to panic-level anxiety. Over time,
the nurse will work with the client to gradually limit the time spent on rituals as part of
behavior therapy.
2. A patient with Schizophrenia is experiencing auditory hallucinations and tells the nurse,
‘The voices are telling me that I am a bad person.’ Which response by the nurse is
therapeutic?
A. I don’t hear any voices; you are just imagining things.
,B. I believe that the voices are real to you, but I do not hear them.
C. What exactly are the voices telling you to do?
D. Let’s ignore the voices and go to the dayroom for a game of cards.
Correct Answer: B
Explanation: This response acknowledges the client’s perception while presenting reality
without being dismissive. It validates the client’s internal experience without agreeing that
the voices exist in the external environment. This helps establish trust and provides a
foundation for reality testing in the therapeutic relationship.
3. A nurse is caring for a client with Anorexia Nervosa who has a BMI of 14. Which finding
should the nurse prioritize as the most immediate concern?
A. Bradycardia and orthostatic hypotension.
B. Presence of lanugo on the back and arms.
C. Client’s statement that they ‘feel fat’ despite being underweight.
D. Amenorrhea for the past six months.
Correct Answer: A
Explanation: Physiological stability is the priority according to Maslow’s Hierarchy of
Needs. Bradycardia and orthostatic hypotension indicate severe cardiovascular
compromise and potential for sudden cardiac arrest. While lanugo and body image
,distortion are common in anorexia, they are not immediately life-threatening compared to
hemodynamic instability.
4. A client is diagnosed with Antisocial Personality Disorder. Which behavior should the nurse
expect to observe during the assessment?
A. Exploitation and lack of remorse for hurting others.
B. Social withdrawal and lack of interest in others.
C. Submissive and clinging behavior toward staff.
D. Excessive emotionality and attention-seeking behavior.
Correct Answer: A
Explanation: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others, often involving deceit and manipulation. These
individuals frequently fail to conform to social norms and lack empathy or remorse for
their actions. Recognizing these traits is crucial for setting firm boundaries in the clinical
setting.
5. Which medication is considered a first-line treatment for a patient diagnosed with
Generalized Anxiety Disorder (GAD)?
A. Escitalopram
B. Haloperidol
C. Chlorpromazine
, D. Benztropine
Correct Answer: A
Explanation: Selective Serotonin Reuptake Inhibitors (SSRIs) such as Escitalopram are
preferred for long-term management of GAD due to their efficacy and safety profile. Unlike
benzodiazepines, they do not carry a risk of physical dependence or significant sedation.
Patients should be educated that these medications take several weeks to reach full
therapeutic effect.
6. A client with Borderline Personality Disorder (BPD) tells Nurse A, ‘You are the only one who
cares. Nurse B is so mean to me.’ This is an example of which defense mechanism?
A. Splitting
B. Reaction Formation
C. Projection
D. Sublimation
Correct Answer: A
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as all good or all bad. This behavior often leads to conflict
among the healthcare team as the client attempts to pit staff members against each other.
Consistent communication among the treatment team is necessary to maintain boundaries
and prevent manipulation.
Nursing Q&A with Rationale | Fortis College
1. A client is admitted to the psychiatric unit with a diagnosis of Obsessive-Compulsive
Disorder (OCD). The nurse observes the client performing repetitive hand-washing rituals.
Which nursing intervention is most appropriate during the initial phase of treatment?
A. Allow the client enough time to perform the ritual to decrease anxiety.
B. Interrupt the ritual to explain the physiological damage to the skin.
C. Request a physician’s order for physical restraints to stop the behavior.
D. Assign a staff member to sit with the client and prevent the hand-washing.
Correct Answer: A
Explanation: During the initial phase of OCD treatment, allowing the client to perform the
ritual is essential to prevent an overwhelming spike in anxiety. Restricting the ritual
abruptly without alternative coping mechanisms can lead to panic-level anxiety. Over time,
the nurse will work with the client to gradually limit the time spent on rituals as part of
behavior therapy.
2. A patient with Schizophrenia is experiencing auditory hallucinations and tells the nurse,
‘The voices are telling me that I am a bad person.’ Which response by the nurse is
therapeutic?
A. I don’t hear any voices; you are just imagining things.
,B. I believe that the voices are real to you, but I do not hear them.
C. What exactly are the voices telling you to do?
D. Let’s ignore the voices and go to the dayroom for a game of cards.
Correct Answer: B
Explanation: This response acknowledges the client’s perception while presenting reality
without being dismissive. It validates the client’s internal experience without agreeing that
the voices exist in the external environment. This helps establish trust and provides a
foundation for reality testing in the therapeutic relationship.
3. A nurse is caring for a client with Anorexia Nervosa who has a BMI of 14. Which finding
should the nurse prioritize as the most immediate concern?
A. Bradycardia and orthostatic hypotension.
B. Presence of lanugo on the back and arms.
C. Client’s statement that they ‘feel fat’ despite being underweight.
D. Amenorrhea for the past six months.
Correct Answer: A
Explanation: Physiological stability is the priority according to Maslow’s Hierarchy of
Needs. Bradycardia and orthostatic hypotension indicate severe cardiovascular
compromise and potential for sudden cardiac arrest. While lanugo and body image
,distortion are common in anorexia, they are not immediately life-threatening compared to
hemodynamic instability.
4. A client is diagnosed with Antisocial Personality Disorder. Which behavior should the nurse
expect to observe during the assessment?
A. Exploitation and lack of remorse for hurting others.
B. Social withdrawal and lack of interest in others.
C. Submissive and clinging behavior toward staff.
D. Excessive emotionality and attention-seeking behavior.
Correct Answer: A
Explanation: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others, often involving deceit and manipulation. These
individuals frequently fail to conform to social norms and lack empathy or remorse for
their actions. Recognizing these traits is crucial for setting firm boundaries in the clinical
setting.
5. Which medication is considered a first-line treatment for a patient diagnosed with
Generalized Anxiety Disorder (GAD)?
A. Escitalopram
B. Haloperidol
C. Chlorpromazine
, D. Benztropine
Correct Answer: A
Explanation: Selective Serotonin Reuptake Inhibitors (SSRIs) such as Escitalopram are
preferred for long-term management of GAD due to their efficacy and safety profile. Unlike
benzodiazepines, they do not carry a risk of physical dependence or significant sedation.
Patients should be educated that these medications take several weeks to reach full
therapeutic effect.
6. A client with Borderline Personality Disorder (BPD) tells Nurse A, ‘You are the only one who
cares. Nurse B is so mean to me.’ This is an example of which defense mechanism?
A. Splitting
B. Reaction Formation
C. Projection
D. Sublimation
Correct Answer: A
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as all good or all bad. This behavior often leads to conflict
among the healthcare team as the client attempts to pit staff members against each other.
Consistent communication among the treatment team is necessary to maintain boundaries
and prevent manipulation.
