NUR 256 Exam 4 V3 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 4) | Galen College of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ behavior. Which nursing intervention is most appropriate?
A. Hold a staff meeting to ensure a consistent approach to the client’s care.
B. Allow the client to choose their own primary nurse each shift.
C. Ignore the behavior to avoid reinforcing the client’s attention-seeking.
D. Provide the client with extra one-on-one time to build rapport.
Correct Answer: A
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views others as all good or all bad. This behavior often causes conflict and
inconsistency among the healthcare team members. Consistency and firm boundaries
among all staff are essential to provide a therapeutic environment and prevent
manipulation.
2. A client is admitted for alcohol detoxification. Which of the following medications should
the nurse expect to administer to manage acute withdrawal symptoms?
A. Disulfiram
B. Naltrexone
,C. Methadone
D. Lorazepam
Correct Answer: D
Explanation: Benzodiazepines such as Lorazepam are the gold standard for managing
acute alcohol withdrawal symptoms. They help prevent seizures and delirium tremens by
providing cross-tolerance with alcohol. Disulfiram and Naltrexone are used for long-term
maintenance of sobriety, not acute detoxification.
3. The nurse is evaluating a child for a potential diagnosis of Conduct Disorder. Which
behavior is most characteristic of this disorder?
A. Argumentative behavior toward authority figures without breaking laws.
B. Frequent temper tantrums and irritability at home.
C. Difficulty sustaining attention in the classroom setting.
D. Persistent pattern of violating the basic rights of others and societal norms.
Correct Answer: D
Explanation: Conduct Disorder involves a repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate societal norms are violated. This
may include aggression to people or animals, destruction of property, and deceitfulness or
theft. In contrast, Oppositional Defiant Disorder (ODD) is characterized by defiance but
generally does not involve illegal or highly aggressive acts.
, 4. A client with Anorexia Nervosa is being monitored for refeeding syndrome. Which
electrolyte imbalance is a hallmark sign of this condition?
A. Hypophosphatemia
B. Hyperkalemia
C. Hypercalcemia
D. Hyponatremia
Correct Answer: A
Explanation: Hypophosphatemia is the hallmark of refeeding syndrome, which occurs
when a severely malnourished patient begins to receive nutritional supplementation. The
sudden shift from catabolic to anabolic metabolism causes insulin release, leading to a
massive uptake of phosphate into the cells. The nurse must monitor electrolyte levels
closely to prevent cardiac arrhythmias and respiratory failure.
5. A nurse is teaching the family of a client with Alzheimer’s disease about Donepezil. Which
statement should the nurse include?
A. This medication will cure the underlying cause of the dementia.
B. You should stop the medication immediately if the client becomes sleepy.
C. Donepezil helps improve cognitive function by increasing acetylcholine levels.
D. The medication should be taken on an empty stomach for best absorption.
Correct Answer: C
Health Nursing | Q&A with Rationale (NUR256
Exam 4) | Galen College of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ behavior. Which nursing intervention is most appropriate?
A. Hold a staff meeting to ensure a consistent approach to the client’s care.
B. Allow the client to choose their own primary nurse each shift.
C. Ignore the behavior to avoid reinforcing the client’s attention-seeking.
D. Provide the client with extra one-on-one time to build rapport.
Correct Answer: A
Explanation: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views others as all good or all bad. This behavior often causes conflict and
inconsistency among the healthcare team members. Consistency and firm boundaries
among all staff are essential to provide a therapeutic environment and prevent
manipulation.
2. A client is admitted for alcohol detoxification. Which of the following medications should
the nurse expect to administer to manage acute withdrawal symptoms?
A. Disulfiram
B. Naltrexone
,C. Methadone
D. Lorazepam
Correct Answer: D
Explanation: Benzodiazepines such as Lorazepam are the gold standard for managing
acute alcohol withdrawal symptoms. They help prevent seizures and delirium tremens by
providing cross-tolerance with alcohol. Disulfiram and Naltrexone are used for long-term
maintenance of sobriety, not acute detoxification.
3. The nurse is evaluating a child for a potential diagnosis of Conduct Disorder. Which
behavior is most characteristic of this disorder?
A. Argumentative behavior toward authority figures without breaking laws.
B. Frequent temper tantrums and irritability at home.
C. Difficulty sustaining attention in the classroom setting.
D. Persistent pattern of violating the basic rights of others and societal norms.
Correct Answer: D
Explanation: Conduct Disorder involves a repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate societal norms are violated. This
may include aggression to people or animals, destruction of property, and deceitfulness or
theft. In contrast, Oppositional Defiant Disorder (ODD) is characterized by defiance but
generally does not involve illegal or highly aggressive acts.
, 4. A client with Anorexia Nervosa is being monitored for refeeding syndrome. Which
electrolyte imbalance is a hallmark sign of this condition?
A. Hypophosphatemia
B. Hyperkalemia
C. Hypercalcemia
D. Hyponatremia
Correct Answer: A
Explanation: Hypophosphatemia is the hallmark of refeeding syndrome, which occurs
when a severely malnourished patient begins to receive nutritional supplementation. The
sudden shift from catabolic to anabolic metabolism causes insulin release, leading to a
massive uptake of phosphate into the cells. The nurse must monitor electrolyte levels
closely to prevent cardiac arrhythmias and respiratory failure.
5. A nurse is teaching the family of a client with Alzheimer’s disease about Donepezil. Which
statement should the nurse include?
A. This medication will cure the underlying cause of the dementia.
B. You should stop the medication immediately if the client becomes sleepy.
C. Donepezil helps improve cognitive function by increasing acetylcholine levels.
D. The medication should be taken on an empty stomach for best absorption.
Correct Answer: C
