NUR 256 Exam 3 V2 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 3) | Galen College of Nursing
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 their primary nurse for each shift.
B. Maintain consistent communication among the treatment team to ensure a unified
approach.
C. Encourage the client to discuss their feelings with multiple staff members.
D. Limit the client’s social interactions until the behavior ceases.
Correct Answer: B
Explanation: Splitting is a defense mechanism where the client perceives others as all
good or all bad. Consistent communication among the treatment team prevents the client
from playing staff against one another. This unified approach is essential for maintaining
therapeutic boundaries and stability.
2. Which physical finding should the nurse prioritize when assessing a client diagnosed with
Anorexia Nervosa?
A. Hyperactive bowel sounds
B. Presence of lanugo on the back and arms
,C. Hypertension and tachycardia
D. Elevated serum potassium levels
Correct Answer: B
Explanation: Lanugo is a fine, downy hair that grows on the body as a compensatory
mechanism to provide insulation in the absence of subcutaneous fat. This is a classic
assessment finding in severe anorexia nervosa. Other common signs include bradycardia
and hypotension rather than hypertension.
3. A client is admitted for alcohol withdrawal. Which medication should the nurse anticipate
administering to prevent seizures?
A. Disulfiram
B. Methadone
C. Naloxone
D. Lorazepam
Correct Answer: D
Explanation: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help stabilize vital signs and significantly reduce the
risk of withdrawal-related seizures and delirium tremens. The nurse should use a
standardized tool like the CIWA scale to determine dosing requirements.
, 4. A 10-year-old client is prescribed Methylphenidate for ADHD. What is the most important
teaching point for the parents regarding administration?
A. Administer the medication right before bedtime.
B. Administer the dose after breakfast to minimize appetite suppression.
C. Double the dose if the child has a particularly active day.
D. Discontinue the medication immediately if the child becomes quiet.
Correct Answer: B
Explanation: Stimulants like Methylphenidate commonly cause appetite suppression,
which can affect growth and development. Administering the medication after a meal
ensures the child receives adequate nutrition before the drug takes effect. The nurse must
also monitor height and weight regularly during therapy.
5. An elderly client in the hospital suddenly becomes confused, agitated, and reports seeing
‘bugs on the wall.’ Which condition does the nurse suspect?
A. Alzheimer’s Disease
B. Major Depressive Disorder
C. Schizotypal Personality Disorder
D. Delirium
Correct Answer: D
Health Nursing | Q&A with Rationale (NUR256
Exam 3) | Galen College of Nursing
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 their primary nurse for each shift.
B. Maintain consistent communication among the treatment team to ensure a unified
approach.
C. Encourage the client to discuss their feelings with multiple staff members.
D. Limit the client’s social interactions until the behavior ceases.
Correct Answer: B
Explanation: Splitting is a defense mechanism where the client perceives others as all
good or all bad. Consistent communication among the treatment team prevents the client
from playing staff against one another. This unified approach is essential for maintaining
therapeutic boundaries and stability.
2. Which physical finding should the nurse prioritize when assessing a client diagnosed with
Anorexia Nervosa?
A. Hyperactive bowel sounds
B. Presence of lanugo on the back and arms
,C. Hypertension and tachycardia
D. Elevated serum potassium levels
Correct Answer: B
Explanation: Lanugo is a fine, downy hair that grows on the body as a compensatory
mechanism to provide insulation in the absence of subcutaneous fat. This is a classic
assessment finding in severe anorexia nervosa. Other common signs include bradycardia
and hypotension rather than hypertension.
3. A client is admitted for alcohol withdrawal. Which medication should the nurse anticipate
administering to prevent seizures?
A. Disulfiram
B. Methadone
C. Naloxone
D. Lorazepam
Correct Answer: D
Explanation: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help stabilize vital signs and significantly reduce the
risk of withdrawal-related seizures and delirium tremens. The nurse should use a
standardized tool like the CIWA scale to determine dosing requirements.
, 4. A 10-year-old client is prescribed Methylphenidate for ADHD. What is the most important
teaching point for the parents regarding administration?
A. Administer the medication right before bedtime.
B. Administer the dose after breakfast to minimize appetite suppression.
C. Double the dose if the child has a particularly active day.
D. Discontinue the medication immediately if the child becomes quiet.
Correct Answer: B
Explanation: Stimulants like Methylphenidate commonly cause appetite suppression,
which can affect growth and development. Administering the medication after a meal
ensures the child receives adequate nutrition before the drug takes effect. The nurse must
also monitor height and weight regularly during therapy.
5. An elderly client in the hospital suddenly becomes confused, agitated, and reports seeing
‘bugs on the wall.’ Which condition does the nurse suspect?
A. Alzheimer’s Disease
B. Major Depressive Disorder
C. Schizotypal Personality Disorder
D. Delirium
Correct Answer: D
