NUR 2459 Exam 4 Actual Exam V3 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is assessing a child with suspected Attention-Deficit/Hyperactivity Disorder
(ADHD). Which finding should the nurse expect to observe?
A. Excessive sleepiness during school hours
B. Preference for solitary, quiet play
C. Superior organizational skills
D. Difficulty waiting for a turn in games
Answer: D
Rationale: Children with ADHD typically exhibit impulsivity, which manifests as a difficulty
in waiting for their turn or interrupting others. The nursing assessment focuses on
identifying core behaviors of inattention, hyperactivity, and impulsivity in multiple
settings. Comprehensive care involves observing these social interactions to develop a
behavioral modification plan.
2. A school-aged child is prescribed methylphenidate for ADHD. Which instruction is most
important for the nurse to include in the teaching plan?
A. Administer the medication at bedtime to promote sleep
B. Expect an increase in appetite during the first month
C. Monitor the child’s height and weight regularly
D. The medication should be taken only on weekends
Answer: C
Rationale: Stimulant medications like methylphenidate can lead to side effects such as
appetite suppression and potential growth retardation. The nurse must educate parents to
monitor growth parameters to ensure the child is meeting developmental milestones.
Providing this education empowers the family to manage the child’s medication regimen
safely and effectively.
3. A nurse is caring for an adolescent client with Anorexia Nervosa who is at 65% of their ideal
body weight. Which is the priority nursing intervention?
A. Encouraging the client to express feelings about body image
B. Allowing the client to plan their own daily menu
C. Setting up a strictly controlled exercise program
D. Monitoring the client’s electrolyte levels and cardiac rhythm
,Answer: D
Rationale: Physiological stability is the priority in severe malnutrition, as electrolyte
imbalances can lead to life-threatening cardiac arrhythmias. The nurse’s initial assessment
must focus on physical safety before addressing the underlying psychological issues related
to body image. This approach reflects the hierarchy of needs where physical survival takes
precedence over self-esteem.
4. A nurse is observing an adolescent with Bulimia Nervosa. Which physical finding is
commonly associated with this disorder?
A. Fine, downy hair (lanugo) over the back
B. Swelling of the parotid glands
C. Severe bradycardia and hypotension
D. Yellowish skin discoloration
Answer: B
Rationale: Repeated vomiting in bulimia nervosa causes the parotid glands to enlarge, a
condition known as sialadenosis. The nurse should perform a comprehensive head-to-toe
assessment to identify physical indicators of purging behaviors. Identifying these signs
helps the nurse validate the client’s symptoms and tailor interventions toward nutritional
rehabilitation.
5. A client with Borderline Personality Disorder (BPD) tells the nurse, ‘The nurse on the night
shift is so much better than you; she really understands me.’ This is an example of which
defense mechanism?
A. Reaction formation
B. Displacement
C. Rationalization
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the client perceives
individuals as either all good or all bad. The nurse must recognize this behavior to maintain
professional boundaries and prevent team conflict. Effective nursing care involves a
consistent, unified approach by the entire healthcare team to minimize the impact of
splitting.
6. Which intervention is most appropriate for a nurse when caring for a client with Antisocial
Personality Disorder who is violating unit rules?
A. Negotiate the rules with the client to encourage cooperation
B. Maintain consistent limits and consequences
, C. Ignore the behavior to avoid giving the client attention
D. Assign the client to lead a peer support group
Answer: B
Rationale: Clients with Antisocial Personality Disorder often test boundaries and
manipulate others for personal gain. The nurse’s role is to provide a structured
environment with clear, firm limits and immediate consequences for rule violations.
Consistency across all staff members is vital to ensure the client understands the
behavioral expectations and remains safe.
7. A nurse is assessing an older adult client for delirium. Which characteristic distinguishes
delirium from dementia?
A. The symptoms develop slowly over several years
B. The client’s level of consciousness is typically unchanged
C. The condition is irreversible and progressive
D. The onset of symptoms is sudden and fluctuating
Answer: D
Rationale: Delirium is characterized by an acute onset, often triggered by an underlying
medical condition, and symptoms that fluctuate throughout the day. In contrast, dementia
is a slow, progressive decline in cognitive function. The nurse must perform a rapid
assessment to identify the cause of delirium, such as an infection or medication reaction, as
it is often reversible.
8. An older adult client with Alzheimer’s Disease often wanders in the hallway at night. Which
nursing intervention should be prioritized for safety?
A. Place the client in soft wrist restraints at bedtime
B. Administer a sedative to ensure the client stays in bed
C. Ensure the hallway is well-lit and free of clutter
D. Lock the client’s door from the outside
Answer: C
Rationale: Ensuring a safe environment is critical for clients with neurocognitive disorders
who are prone to wandering and falls. The nurse should use non-pharmacological
interventions like adequate lighting and clearing pathways before considering more
restrictive measures. This patient-centered approach preserves the client’s dignity while
mitigating the risk of injury.
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is assessing a child with suspected Attention-Deficit/Hyperactivity Disorder
(ADHD). Which finding should the nurse expect to observe?
A. Excessive sleepiness during school hours
B. Preference for solitary, quiet play
C. Superior organizational skills
D. Difficulty waiting for a turn in games
Answer: D
Rationale: Children with ADHD typically exhibit impulsivity, which manifests as a difficulty
in waiting for their turn or interrupting others. The nursing assessment focuses on
identifying core behaviors of inattention, hyperactivity, and impulsivity in multiple
settings. Comprehensive care involves observing these social interactions to develop a
behavioral modification plan.
2. A school-aged child is prescribed methylphenidate for ADHD. Which instruction is most
important for the nurse to include in the teaching plan?
A. Administer the medication at bedtime to promote sleep
B. Expect an increase in appetite during the first month
C. Monitor the child’s height and weight regularly
D. The medication should be taken only on weekends
Answer: C
Rationale: Stimulant medications like methylphenidate can lead to side effects such as
appetite suppression and potential growth retardation. The nurse must educate parents to
monitor growth parameters to ensure the child is meeting developmental milestones.
Providing this education empowers the family to manage the child’s medication regimen
safely and effectively.
3. A nurse is caring for an adolescent client with Anorexia Nervosa who is at 65% of their ideal
body weight. Which is the priority nursing intervention?
A. Encouraging the client to express feelings about body image
B. Allowing the client to plan their own daily menu
C. Setting up a strictly controlled exercise program
D. Monitoring the client’s electrolyte levels and cardiac rhythm
,Answer: D
Rationale: Physiological stability is the priority in severe malnutrition, as electrolyte
imbalances can lead to life-threatening cardiac arrhythmias. The nurse’s initial assessment
must focus on physical safety before addressing the underlying psychological issues related
to body image. This approach reflects the hierarchy of needs where physical survival takes
precedence over self-esteem.
4. A nurse is observing an adolescent with Bulimia Nervosa. Which physical finding is
commonly associated with this disorder?
A. Fine, downy hair (lanugo) over the back
B. Swelling of the parotid glands
C. Severe bradycardia and hypotension
D. Yellowish skin discoloration
Answer: B
Rationale: Repeated vomiting in bulimia nervosa causes the parotid glands to enlarge, a
condition known as sialadenosis. The nurse should perform a comprehensive head-to-toe
assessment to identify physical indicators of purging behaviors. Identifying these signs
helps the nurse validate the client’s symptoms and tailor interventions toward nutritional
rehabilitation.
5. A client with Borderline Personality Disorder (BPD) tells the nurse, ‘The nurse on the night
shift is so much better than you; she really understands me.’ This is an example of which
defense mechanism?
A. Reaction formation
B. Displacement
C. Rationalization
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the client perceives
individuals as either all good or all bad. The nurse must recognize this behavior to maintain
professional boundaries and prevent team conflict. Effective nursing care involves a
consistent, unified approach by the entire healthcare team to minimize the impact of
splitting.
6. Which intervention is most appropriate for a nurse when caring for a client with Antisocial
Personality Disorder who is violating unit rules?
A. Negotiate the rules with the client to encourage cooperation
B. Maintain consistent limits and consequences
, C. Ignore the behavior to avoid giving the client attention
D. Assign the client to lead a peer support group
Answer: B
Rationale: Clients with Antisocial Personality Disorder often test boundaries and
manipulate others for personal gain. The nurse’s role is to provide a structured
environment with clear, firm limits and immediate consequences for rule violations.
Consistency across all staff members is vital to ensure the client understands the
behavioral expectations and remains safe.
7. A nurse is assessing an older adult client for delirium. Which characteristic distinguishes
delirium from dementia?
A. The symptoms develop slowly over several years
B. The client’s level of consciousness is typically unchanged
C. The condition is irreversible and progressive
D. The onset of symptoms is sudden and fluctuating
Answer: D
Rationale: Delirium is characterized by an acute onset, often triggered by an underlying
medical condition, and symptoms that fluctuate throughout the day. In contrast, dementia
is a slow, progressive decline in cognitive function. The nurse must perform a rapid
assessment to identify the cause of delirium, such as an infection or medication reaction, as
it is often reversible.
8. An older adult client with Alzheimer’s Disease often wanders in the hallway at night. Which
nursing intervention should be prioritized for safety?
A. Place the client in soft wrist restraints at bedtime
B. Administer a sedative to ensure the client stays in bed
C. Ensure the hallway is well-lit and free of clutter
D. Lock the client’s door from the outside
Answer: C
Rationale: Ensuring a safe environment is critical for clients with neurocognitive disorders
who are prone to wandering and falls. The nurse should use non-pharmacological
interventions like adequate lighting and clearing pathways before considering more
restrictive measures. This patient-centered approach preserves the client’s dignity while
mitigating the risk of injury.
