NUR 256 Exam 4 V1 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 4) | Galen College of Nursing
1. A nurse is assessing a client who has a suspected diagnosis of delirium. Which of the
following findings is the most characteristic of this condition?
A. Sudden onset of confusion and fluctuating levels of consciousness
B. Relatively stable level of consciousness throughout the day
C. Slow and progressive decline in memory
D. Permanent and irreversible cognitive deficits
Correct Answer: A
Explanation: Delirium is characterized by an acute, rapid onset of confusion and cognitive
changes. Unlike dementia, which is progressive and irreversible, delirium is often
reversible if the underlying cause is addressed. Nurses must monitor for fluctuating levels
of awareness, which is a hallmark sign of this condition.
2. A nurse is caring for a client with Borderline Personality Disorder who is using splitting
behavior. Which action should the nurse take?
A. Allow the client to choose their favorite nurse for all shifts
B. Hold a staff meeting to ensure a consistent approach by all team members
C. Argue with the client about their perceptions of other staff members
,D. Limit all interactions with the client to five minutes or less
Correct Answer: B
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views people as all good or all bad. Consistency among the treatment team
is vital to prevent the client from playing staff members against each other. Regular staff
meetings help maintain clear boundaries and a unified therapeutic plan.
3. A client diagnosed with Anorexia Nervosa is being admitted to an inpatient unit. Which of
the following should be the nurse’s priority assessment?
A. Assessment of the client’s distorted body image
B. Calculation of the client’s current Body Mass Index (BMI)
C. Measurement of the client’s serum electrolyte levels
D. Evaluation of the client’s relationship with their parents
Correct Answer: C
Explanation: In cases of severe Anorexia Nervosa, physiological stability is the immediate
priority. Electrolyte imbalances, particularly hypokalemia, can lead to life-threatening
cardiac arrhythmias. While psychological and nutritional assessments are important, the
risk of acute medical collapse makes lab values the priority.
4. The nurse is providing education to the parents of a child newly diagnosed with ADHD who
is starting methylphenidate. Which instruction is most important?
A. Administer the medication right before the child goes to bed
, B. Expect the child to have an increased appetite while on this drug
C. Monitor the child’s weight and height regularly during therapy
D. Discontinue the medication immediately if the child becomes focused
Correct Answer: C
Explanation: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation. Parents must track growth parameters to ensure the
child is developing at a healthy rate. The medication should typically be given in the
morning to avoid insomnia and should never be stopped abruptly without medical
guidance.
5. A client with Antisocial Personality Disorder is admitted to the psychiatric unit. Which
nursing intervention is appropriate when the client attempts to manipulate the nurse?
A. Ignore the behavior to avoid giving it positive reinforcement
B. Allow the client to have special privileges to build trust
C. Discuss the client’s childhood trauma to find the cause of the behavior
D. Set firm, clear limits on the client’s behavior and expectations
Correct Answer: D
Explanation: Clients with Antisocial Personality Disorder often exhibit manipulative and
exploitative behaviors towards others. Establishing and strictly adhering to clear
Health Nursing | Q&A with Rationale (NUR256
Exam 4) | Galen College of Nursing
1. A nurse is assessing a client who has a suspected diagnosis of delirium. Which of the
following findings is the most characteristic of this condition?
A. Sudden onset of confusion and fluctuating levels of consciousness
B. Relatively stable level of consciousness throughout the day
C. Slow and progressive decline in memory
D. Permanent and irreversible cognitive deficits
Correct Answer: A
Explanation: Delirium is characterized by an acute, rapid onset of confusion and cognitive
changes. Unlike dementia, which is progressive and irreversible, delirium is often
reversible if the underlying cause is addressed. Nurses must monitor for fluctuating levels
of awareness, which is a hallmark sign of this condition.
2. A nurse is caring for a client with Borderline Personality Disorder who is using splitting
behavior. Which action should the nurse take?
A. Allow the client to choose their favorite nurse for all shifts
B. Hold a staff meeting to ensure a consistent approach by all team members
C. Argue with the client about their perceptions of other staff members
,D. Limit all interactions with the client to five minutes or less
Correct Answer: B
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views people as all good or all bad. Consistency among the treatment team
is vital to prevent the client from playing staff members against each other. Regular staff
meetings help maintain clear boundaries and a unified therapeutic plan.
3. A client diagnosed with Anorexia Nervosa is being admitted to an inpatient unit. Which of
the following should be the nurse’s priority assessment?
A. Assessment of the client’s distorted body image
B. Calculation of the client’s current Body Mass Index (BMI)
C. Measurement of the client’s serum electrolyte levels
D. Evaluation of the client’s relationship with their parents
Correct Answer: C
Explanation: In cases of severe Anorexia Nervosa, physiological stability is the immediate
priority. Electrolyte imbalances, particularly hypokalemia, can lead to life-threatening
cardiac arrhythmias. While psychological and nutritional assessments are important, the
risk of acute medical collapse makes lab values the priority.
4. The nurse is providing education to the parents of a child newly diagnosed with ADHD who
is starting methylphenidate. Which instruction is most important?
A. Administer the medication right before the child goes to bed
, B. Expect the child to have an increased appetite while on this drug
C. Monitor the child’s weight and height regularly during therapy
D. Discontinue the medication immediately if the child becomes focused
Correct Answer: C
Explanation: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation. Parents must track growth parameters to ensure the
child is developing at a healthy rate. The medication should typically be given in the
morning to avoid insomnia and should never be stopped abruptly without medical
guidance.
5. A client with Antisocial Personality Disorder is admitted to the psychiatric unit. Which
nursing intervention is appropriate when the client attempts to manipulate the nurse?
A. Ignore the behavior to avoid giving it positive reinforcement
B. Allow the client to have special privileges to build trust
C. Discuss the client’s childhood trauma to find the cause of the behavior
D. Set firm, clear limits on the client’s behavior and expectations
Correct Answer: D
Explanation: Clients with Antisocial Personality Disorder often exhibit manipulative and
exploitative behaviors towards others. Establishing and strictly adhering to clear
