Q NUR 2459 Exam 4 Actual Exam V2 | NUR 2459 Mental and
Behavioral Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse best respond to this behavior?
A. Allow the client to choose which nurse they prefer to work with for the shift.
B. Explain to the client that their behavior is hurting the feelings of the nursing staff.
C. Confront the client immediately about their manipulative behavior in a group setting.
D. Hold a staff meeting to ensure all team members are following a consistent plan of care.
Answer: D
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad, which can lead to conflict among staff members. Maintaining consistency and a
united front among the treatment team is the most effective way to manage this behavior
and prevent staff manipulation. This approach provides the client with a stable
environment and reinforces healthy boundaries.
2. A client is admitted for alcohol detoxification. Which of the following assessment findings
would indicate the client is experiencing alcohol withdrawal delirium?
A. Bradycardia and hypotension
B. Visual hallucinations and cardiac arrhythmias
C. Hypersomnia and increased appetite
D. Coherent speech and oriented to person, place, and time
Answer: B
Rationale: Alcohol withdrawal delirium, or delirium tremens, is a medical emergency
characterized by severe autonomic hyperactivity and sensory disturbances. Symptoms
typically include tachycardia, diaphoresis, fever, and visual or tactile hallucinations.
Monitoring for these symptoms is critical because they can lead to seizures or
cardiovascular collapse if not treated promptly.
3. A nurse is assessing an adolescent client with Anorexia Nervosa. Which physical finding
would warrant immediate hospitalization?
A. A serum potassium level of 3.6 mEq/L
B. Body weight that is 15% below ideal
C. Heart rate of 38 beats per minute
D. Lanugo on the back and extremities
,Answer: C
Rationale: Severe bradycardia, typically defined as a heart rate below 40 bpm, indicates
significant cardiovascular instability and requires acute medical intervention. Other
criteria for hospitalization include electrolyte imbalances, severe dehydration, or a weight
loss of more than 30% over 6 months. Prioritizing physiological stability is the first step in
the treatment of eating disorders.
4. A client with Alzheimer’s disease frequently wanders and becomes agitated in the evening.
Which intervention should the nurse implement first?
A. Administer a PRN dose of haloperidol to calm the client.
B. Place the client in soft wrist restraints to prevent wandering.
C. Provide a quiet, low-stimulation environment with soft lighting.
D. Turn on bright lights in the hallway to increase visibility.
Answer: C
Rationale: Sundowning is a common phenomenon in dementia where agitation increases
as daylight fades. Providing a calm, low-stimulus environment helps reduce sensory
overload and minimizes agitation. Non-pharmacological interventions should always be
attempted before considering chemical or physical restraints.
5. The nurse is educating the parents of a child newly diagnosed with ADHD who has been
prescribed methylphenidate. What should the nurse include in the teaching?
A. Administer the medication right before the child goes to sleep.
B. Encourage a high-calorie snack late at night to prevent weight gain.
C. Monitor the child’s height and weight regularly.
D. Expect the child to become very drowsy during the first week.
Answer: C
Rationale: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation. Regular monitoring of growth parameters is essential
to ensure the child is developing appropriately. The medication should be given earlier in
the day to avoid insomnia and is usually taken after meals to minimize appetite loss.
6. A client with Antisocial Personality Disorder is admitted to the unit. Which nursing
intervention is most appropriate for this client?
A. Provide a warm, nurturing environment to build trust.
B. Encourage the client to lead group therapy sessions.
C. Allow the client to negotiate the rules of the unit.
, D. Set clear, firm limits on behavior and enforce consequences.
Answer: D
Rationale: Clients with Antisocial Personality Disorder often disregard the rights of others
and may be manipulative or aggressive. Setting firm, consistent limits is necessary to
maintain safety and provide a structured environment. It is important for the nurse to
remain objective and avoid being drawn into the client’s attempts to manipulate the
system.
7. A client is brought to the emergency department with suspected opioid overdose. Which
assessment finding is most consistent with this condition?
A. Pinpoint pupils and respiratory depression
B. Hyperreflexia and agitation
C. Dilated pupils and tachycardia
D. High fever and muscle rigidity
Answer: A
Rationale: Opioid overdose typically presents with the ‘opioid triad’: pinpoint pupils,
respiratory depression, and a decreased level of consciousness. This is a life-threatening
emergency that requires immediate administration of an opioid antagonist like naloxone.
Nurses must prioritize airway management and oxygenation in these patients.
8. A nurse is assessing a client with Bulimia Nervosa. Which finding is a common physical
complication of this disorder?
A. Increased bone density
B. Excessive hair growth on the face
C. Dental caries and parotid gland swelling
D. Hypertension and bradycardia
Answer: C
Rationale: Frequent vomiting in Bulimia Nervosa exposes the teeth to stomach acid,
leading to dental enamel erosion and caries. The parotid glands may also become swollen
due to the repetitive stimulation of the salivary glands during binging and purging. These
physical markers are helpful for clinicians in identifying the disorder even when the client’s
weight remains within a normal range.
9. An elderly client is admitted with sudden onset confusion and fluctuating levels of
consciousness. Which condition should the nurse suspect first?
A. Delirium
B. Vascular Dementia
Behavioral Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse best respond to this behavior?
A. Allow the client to choose which nurse they prefer to work with for the shift.
B. Explain to the client that their behavior is hurting the feelings of the nursing staff.
C. Confront the client immediately about their manipulative behavior in a group setting.
D. Hold a staff meeting to ensure all team members are following a consistent plan of care.
Answer: D
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad, which can lead to conflict among staff members. Maintaining consistency and a
united front among the treatment team is the most effective way to manage this behavior
and prevent staff manipulation. This approach provides the client with a stable
environment and reinforces healthy boundaries.
2. A client is admitted for alcohol detoxification. Which of the following assessment findings
would indicate the client is experiencing alcohol withdrawal delirium?
A. Bradycardia and hypotension
B. Visual hallucinations and cardiac arrhythmias
C. Hypersomnia and increased appetite
D. Coherent speech and oriented to person, place, and time
Answer: B
Rationale: Alcohol withdrawal delirium, or delirium tremens, is a medical emergency
characterized by severe autonomic hyperactivity and sensory disturbances. Symptoms
typically include tachycardia, diaphoresis, fever, and visual or tactile hallucinations.
Monitoring for these symptoms is critical because they can lead to seizures or
cardiovascular collapse if not treated promptly.
3. A nurse is assessing an adolescent client with Anorexia Nervosa. Which physical finding
would warrant immediate hospitalization?
A. A serum potassium level of 3.6 mEq/L
B. Body weight that is 15% below ideal
C. Heart rate of 38 beats per minute
D. Lanugo on the back and extremities
,Answer: C
Rationale: Severe bradycardia, typically defined as a heart rate below 40 bpm, indicates
significant cardiovascular instability and requires acute medical intervention. Other
criteria for hospitalization include electrolyte imbalances, severe dehydration, or a weight
loss of more than 30% over 6 months. Prioritizing physiological stability is the first step in
the treatment of eating disorders.
4. A client with Alzheimer’s disease frequently wanders and becomes agitated in the evening.
Which intervention should the nurse implement first?
A. Administer a PRN dose of haloperidol to calm the client.
B. Place the client in soft wrist restraints to prevent wandering.
C. Provide a quiet, low-stimulation environment with soft lighting.
D. Turn on bright lights in the hallway to increase visibility.
Answer: C
Rationale: Sundowning is a common phenomenon in dementia where agitation increases
as daylight fades. Providing a calm, low-stimulus environment helps reduce sensory
overload and minimizes agitation. Non-pharmacological interventions should always be
attempted before considering chemical or physical restraints.
5. The nurse is educating the parents of a child newly diagnosed with ADHD who has been
prescribed methylphenidate. What should the nurse include in the teaching?
A. Administer the medication right before the child goes to sleep.
B. Encourage a high-calorie snack late at night to prevent weight gain.
C. Monitor the child’s height and weight regularly.
D. Expect the child to become very drowsy during the first week.
Answer: C
Rationale: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation. Regular monitoring of growth parameters is essential
to ensure the child is developing appropriately. The medication should be given earlier in
the day to avoid insomnia and is usually taken after meals to minimize appetite loss.
6. A client with Antisocial Personality Disorder is admitted to the unit. Which nursing
intervention is most appropriate for this client?
A. Provide a warm, nurturing environment to build trust.
B. Encourage the client to lead group therapy sessions.
C. Allow the client to negotiate the rules of the unit.
, D. Set clear, firm limits on behavior and enforce consequences.
Answer: D
Rationale: Clients with Antisocial Personality Disorder often disregard the rights of others
and may be manipulative or aggressive. Setting firm, consistent limits is necessary to
maintain safety and provide a structured environment. It is important for the nurse to
remain objective and avoid being drawn into the client’s attempts to manipulate the
system.
7. A client is brought to the emergency department with suspected opioid overdose. Which
assessment finding is most consistent with this condition?
A. Pinpoint pupils and respiratory depression
B. Hyperreflexia and agitation
C. Dilated pupils and tachycardia
D. High fever and muscle rigidity
Answer: A
Rationale: Opioid overdose typically presents with the ‘opioid triad’: pinpoint pupils,
respiratory depression, and a decreased level of consciousness. This is a life-threatening
emergency that requires immediate administration of an opioid antagonist like naloxone.
Nurses must prioritize airway management and oxygenation in these patients.
8. A nurse is assessing a client with Bulimia Nervosa. Which finding is a common physical
complication of this disorder?
A. Increased bone density
B. Excessive hair growth on the face
C. Dental caries and parotid gland swelling
D. Hypertension and bradycardia
Answer: C
Rationale: Frequent vomiting in Bulimia Nervosa exposes the teeth to stomach acid,
leading to dental enamel erosion and caries. The parotid glands may also become swollen
due to the repetitive stimulation of the salivary glands during binging and purging. These
physical markers are helpful for clinicians in identifying the disorder even when the client’s
weight remains within a normal range.
9. An elderly client is admitted with sudden onset confusion and fluctuating levels of
consciousness. Which condition should the nurse suspect first?
A. Delirium
B. Vascular Dementia
