,NSG 221 Mental Health Exam 4 | Herzing
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who frequently uses
splitting when interacting with staff. Which nursing action is most appropriate to address this
behavior?
A) Allow the client to select their preferred nurse for each shift
B) Hold a staff meeting to ensure a consistent approach and unified plan of care
C) Ignore the behavior as a common attention-seeking mechanism
D) Provide the client with extra one-on-one time to build trust
Correct Answer: Hold a staff meeting to ensure a consistent approach and unified plan of care
Rationale: Splitting is a defense mechanism where the client views people as all good or all bad, which
can cause conflict among staff members. Holding a staff meeting ensures a consistent approach to
boundaries and care, preventing manipulation of staff roles. Consistency is the most critical
intervention for clients with Cluster B personality disorders.
2. A client is admitted to the emergency department with suspected opioid overdose. Which clinical
manifestation should the nurse anticipate?
A) Tachycardia and dilated pupils
B) Respiratory depression and pinpoint pupils
C) Hypertension and hyperreflexia
D) Increased bowel sounds and diaphoresis
Correct Answer: Respiratory depression and pinpoint pupils
Rationale: Opioid toxicity presents with the "opioid triad" of coma, respiratory depression, and
pinpoint pupils (miosis). Monitoring respiratory rate is the priority as it can lead to respiratory arrest.
The nurse should be prepared to administer Naloxone, the specific antagonist for opioid-induced CNS
depression.
3. A nurse is assessing a client with Anorexia Nervosa. Which physical finding would support this
diagnosis?
,A) Parotid gland swelling and dental caries
B) The presence of lanugo and bradycardia
C) Tachycardia and hypertension
D) Heavy menstrual cycles and oily skin
Correct Answer: The presence of lanugo and bradycardia
Rationale: Lanugo, fine downy hair, is a compensatory mechanism the body uses to provide insulation
due to loss of subcutaneous fat. Bradycardia and hypotension are common cardiovascular responses
to the starved state. Other symptoms include amenorrhea and core body temperature below normal
limits.
4. A client with Antisocial Personality Disorder is being aggressive toward another peer. What is the
priority nursing intervention?
A) Ask the client to explain why they are angry at their peer
B) Encourage the client to express their feelings in a group setting
C) Set clear, firm limits on behavior and consequences
D) Administer a sedative immediately to prevent further escalation
Correct Answer: Set clear, firm limits on behavior and consequences
Rationale: Clients with Antisocial Personality Disorder require clear boundaries and consequences for
inappropriate behavior. Setting firm limits establishes safety and accountability. Exploring feelings or
encouraging expression may not be effective as these clients often lack remorse and can be
manipulative.
5. Which of the following is a key differentiating factor between Delirium and Dementia?
A) Dementia has a rapid, acute onset while Delirium is chronic
B) Delirium is characterized by a fluctuating level of consciousness, whereas Dementia is stable
C) Delirium only occurs in elderly patients, while Dementia occurs at any age
D) Memory loss is only present in Dementia and not in Delirium
, Correct Answer: Delirium is characterized by a fluctuating level of consciousness, whereas Dementia is
stable
Rationale: Delirium is an acute syndrome with disturbances in consciousness and cognition that
develop over a short period. Unlike Dementia, which involves progressive and stable decline, Delirium
involves fluctuations in alertness throughout the day. Identifying the underlying cause of delirium is
vital as it is often reversible.
6. A nurse is providing education to a client starting Disulfiram (Antabuse) for alcohol use disorder.
Which instruction is the most critical to include?
A) Avoid all products containing alcohol, including mouthwash and aftershave
B) The medication should be taken only when you feel an urge to drink
C) Stop the medication immediately if you experience a metallic taste
D) You can safely consume alcohol 24 hours after your last dose
Correct Answer: Avoid all products containing alcohol, including mouthwash and aftershave
Rationale: Disulfiram causes a severe adverse reaction when even small amounts of alcohol are
ingested or absorbed through the skin. Clients must read labels on products like cough syrups,
vinegars, and topical solutions. The reaction can include flushing, nausea, vomiting, and potentially
life-threatening cardiovascular effects.
7. A nurse is assessing a client with Borderline Personality Disorder. Which behavior is most
characteristic of this diagnosis?
A) Extreme fear of social situations and public speaking
B) Preoccupation with orderliness, perfectionism, and control
C) Demonstration of splitting behavior in relationships with staff
D) Lack of remorse after violating the rights of others
Correct Answer: Demonstration of splitting behavior in relationships with staff
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who frequently uses
splitting when interacting with staff. Which nursing action is most appropriate to address this
behavior?
A) Allow the client to select their preferred nurse for each shift
B) Hold a staff meeting to ensure a consistent approach and unified plan of care
C) Ignore the behavior as a common attention-seeking mechanism
D) Provide the client with extra one-on-one time to build trust
Correct Answer: Hold a staff meeting to ensure a consistent approach and unified plan of care
Rationale: Splitting is a defense mechanism where the client views people as all good or all bad, which
can cause conflict among staff members. Holding a staff meeting ensures a consistent approach to
boundaries and care, preventing manipulation of staff roles. Consistency is the most critical
intervention for clients with Cluster B personality disorders.
2. A client is admitted to the emergency department with suspected opioid overdose. Which clinical
manifestation should the nurse anticipate?
A) Tachycardia and dilated pupils
B) Respiratory depression and pinpoint pupils
C) Hypertension and hyperreflexia
D) Increased bowel sounds and diaphoresis
Correct Answer: Respiratory depression and pinpoint pupils
Rationale: Opioid toxicity presents with the "opioid triad" of coma, respiratory depression, and
pinpoint pupils (miosis). Monitoring respiratory rate is the priority as it can lead to respiratory arrest.
The nurse should be prepared to administer Naloxone, the specific antagonist for opioid-induced CNS
depression.
3. A nurse is assessing a client with Anorexia Nervosa. Which physical finding would support this
diagnosis?
,A) Parotid gland swelling and dental caries
B) The presence of lanugo and bradycardia
C) Tachycardia and hypertension
D) Heavy menstrual cycles and oily skin
Correct Answer: The presence of lanugo and bradycardia
Rationale: Lanugo, fine downy hair, is a compensatory mechanism the body uses to provide insulation
due to loss of subcutaneous fat. Bradycardia and hypotension are common cardiovascular responses
to the starved state. Other symptoms include amenorrhea and core body temperature below normal
limits.
4. A client with Antisocial Personality Disorder is being aggressive toward another peer. What is the
priority nursing intervention?
A) Ask the client to explain why they are angry at their peer
B) Encourage the client to express their feelings in a group setting
C) Set clear, firm limits on behavior and consequences
D) Administer a sedative immediately to prevent further escalation
Correct Answer: Set clear, firm limits on behavior and consequences
Rationale: Clients with Antisocial Personality Disorder require clear boundaries and consequences for
inappropriate behavior. Setting firm limits establishes safety and accountability. Exploring feelings or
encouraging expression may not be effective as these clients often lack remorse and can be
manipulative.
5. Which of the following is a key differentiating factor between Delirium and Dementia?
A) Dementia has a rapid, acute onset while Delirium is chronic
B) Delirium is characterized by a fluctuating level of consciousness, whereas Dementia is stable
C) Delirium only occurs in elderly patients, while Dementia occurs at any age
D) Memory loss is only present in Dementia and not in Delirium
, Correct Answer: Delirium is characterized by a fluctuating level of consciousness, whereas Dementia is
stable
Rationale: Delirium is an acute syndrome with disturbances in consciousness and cognition that
develop over a short period. Unlike Dementia, which involves progressive and stable decline, Delirium
involves fluctuations in alertness throughout the day. Identifying the underlying cause of delirium is
vital as it is often reversible.
6. A nurse is providing education to a client starting Disulfiram (Antabuse) for alcohol use disorder.
Which instruction is the most critical to include?
A) Avoid all products containing alcohol, including mouthwash and aftershave
B) The medication should be taken only when you feel an urge to drink
C) Stop the medication immediately if you experience a metallic taste
D) You can safely consume alcohol 24 hours after your last dose
Correct Answer: Avoid all products containing alcohol, including mouthwash and aftershave
Rationale: Disulfiram causes a severe adverse reaction when even small amounts of alcohol are
ingested or absorbed through the skin. Clients must read labels on products like cough syrups,
vinegars, and topical solutions. The reaction can include flushing, nausea, vomiting, and potentially
life-threatening cardiovascular effects.
7. A nurse is assessing a client with Borderline Personality Disorder. Which behavior is most
characteristic of this diagnosis?
A) Extreme fear of social situations and public speaking
B) Preoccupation with orderliness, perfectionism, and control
C) Demonstration of splitting behavior in relationships with staff
D) Lack of remorse after violating the rights of others
Correct Answer: Demonstration of splitting behavior in relationships with staff
