NUR 253 Exam 4 Actual Exam V3 | NUR 253 Mental Health Nursing
(NUR253 Exam 4) | Galen College of Nursing
1. A 78-year-old patient is admitted with suspected delirium. Which assessment finding
should the nurse prioritize to differentiate delirium from dementia?
A. Gradual loss of cognitive function over several years.
B. Presence of long-term memory deficits.
C. Persistent difficulty finding common words during conversation.
D. Fluctuating levels of consciousness throughout the day.
Answer: D
Rationale: Delirium is characterized by an acute onset and fluctuating levels of
consciousness, whereas dementia is typically progressive and stable. Clinical judgment
requires the nurse to recognize that sudden changes in orientation or alertness are medical
emergencies. The nurse must assess for underlying causes like infection or medication
toxicity immediately.
2. A patient with Alcohol Use Disorder is experiencing autonomic hyperactivity, tremors, and
agitation. Which medication should the nurse anticipate administering first?
A. Disulfiram (Antabuse)
B. Lorazepam (Ativan)
C. Naltrexone (ReVia)
D. Methadone
Answer: B
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal to prevent seizures and delirium tremens. The nurse must monitor the
patient using the CIWA-Ar scale to determine dosing frequency. Safety is the priority as
withdrawal can be life-threatening if untreated.
3. An adolescent female is admitted for Anorexia Nervosa with a BMI of 14. Which clinical
finding is the most critical indication for immediate medical stabilization?
A. Heart rate of 38 beats per minute.
B. Lanugo present on the back and arms.
C. Amenorrhea for the past six months.
D. Peripheral edema in the lower extremities.
,Answer: A
Rationale: Severe bradycardia (HR < 40) indicates critical cardiovascular compromise and
requires immediate hospitalization. While lanugo and amenorrhea are diagnostic signs,
they do not represent acute physiological instability. The nurse must prioritize vital signs
to prevent sudden cardiac arrest in eating disorder patients.
4. A patient with Borderline Personality Disorder (BPD) tells Nurse A, ‘You are the only one
who cares. Nurse B is so mean and incompetent.’ What is the nurse’s best response?
A. All nurses in this unit follow the same care plan for your safety.
B. I appreciate the compliment, but all our staff are well-trained.
C. It sounds like you are frustrated; let’s discuss your treatment plan.
D. I will talk to Nurse B and let her know you are upset.
Answer: A
Rationale: Splitting is a common defense mechanism in BPD where the patient views staff
as either ‘all good’ or ‘all bad.’ The nursing intervention must focus on consistent limit-
setting and maintaining a unified staff approach. By reinforcing the team care plan, the
nurse prevents manipulation and promotes milieu stability.
5. A patient is prescribed Donepezil (Aricept) for moderate Alzheimer’s disease. Which side
effect should the nurse instruct the family to monitor most closely?
A. Severe hypertension.
B. Extrapyramidal symptoms.
C. Syncope and bradycardia.
D. Urinary retention.
Answer: C
Rationale: Cholinesterase inhibitors like Donepezil enhance parasympathetic activity,
which can lead to bradycardia and syncope, increasing fall risks. Families must be educated
to monitor heart rate and ensure the environment is safe to prevent fractures. This is a vital
safety assessment in the geriatric population.
6. Which assessment finding would the nurse expect in a patient who has just ingested a high
dose of Cocaine?
A. Constricted pupils and drowsiness.
B. Hypotension and bradypnea.
C. Dilated pupils and tachycardia.
D. Increased appetite and hypersomnia.
, Answer: C
Rationale: Cocaine is a central nervous system stimulant that causes a sympathetic ‘fight
or flight’ response, including pupillary dilation and increased heart rate. The nurse must
monitor for cardiac arrhythmias and myocardial infarction during the intoxication phase.
Safety monitoring is paramount due to the high potential for agitation and violence.
7. A patient with Antisocial Personality Disorder is caught smoking in a non-smoking area.
The patient says, ‘I’ve had a bad day, just let it slide once.’ What is the nurse’s most
appropriate action?
A. Allow the patient to finish the cigarette to prevent escalation.
B. Explain the health risks of smoking to the patient.
C. Ignore the behavior unless the patient becomes aggressive.
D. Inform the patient that smoking is a violation of the rules and apply the agreed-upon
consequence.
Answer: D
Rationale: Consistent limit-setting is the primary intervention for patients with Antisocial
Personality Disorder who frequently challenge boundaries. Allowing exceptions reinforces
manipulative behavior and undermines the therapeutic milieu. Nurses must maintain
professional neutrality while enforcing unit rules to promote behavioral accountability.
8. In the ‘Refeeding’ phase for a patient with severe malnutrition, which laboratory value is
the most critical for the nurse to monitor?
A. Serum Potassium.
B. Blood Urea Nitrogen (BUN).
C. Serum Phosphate.
D. Hemoglobin A1c.
Answer: C
Rationale: Refeeding Syndrome is characterized by a dangerous drop in serum phosphate
as the body shifts from a catabolic to an anabolic state. Hypophosphatemia can lead to
cardiac failure, seizures, and respiratory distress. The nurse must monitor electrolytes
daily and advocate for slow reintroduction of nutrients.
9. A nurse is caring for a patient with Bulimia Nervosa. Which physical assessment finding is
most likely associated with the use of self-induced vomiting?
A. Development of a fine downy hair on the face.
B. High blood pressure.
C. Hypertrophy of the parotid glands.
(NUR253 Exam 4) | Galen College of Nursing
1. A 78-year-old patient is admitted with suspected delirium. Which assessment finding
should the nurse prioritize to differentiate delirium from dementia?
A. Gradual loss of cognitive function over several years.
B. Presence of long-term memory deficits.
C. Persistent difficulty finding common words during conversation.
D. Fluctuating levels of consciousness throughout the day.
Answer: D
Rationale: Delirium is characterized by an acute onset and fluctuating levels of
consciousness, whereas dementia is typically progressive and stable. Clinical judgment
requires the nurse to recognize that sudden changes in orientation or alertness are medical
emergencies. The nurse must assess for underlying causes like infection or medication
toxicity immediately.
2. A patient with Alcohol Use Disorder is experiencing autonomic hyperactivity, tremors, and
agitation. Which medication should the nurse anticipate administering first?
A. Disulfiram (Antabuse)
B. Lorazepam (Ativan)
C. Naltrexone (ReVia)
D. Methadone
Answer: B
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal to prevent seizures and delirium tremens. The nurse must monitor the
patient using the CIWA-Ar scale to determine dosing frequency. Safety is the priority as
withdrawal can be life-threatening if untreated.
3. An adolescent female is admitted for Anorexia Nervosa with a BMI of 14. Which clinical
finding is the most critical indication for immediate medical stabilization?
A. Heart rate of 38 beats per minute.
B. Lanugo present on the back and arms.
C. Amenorrhea for the past six months.
D. Peripheral edema in the lower extremities.
,Answer: A
Rationale: Severe bradycardia (HR < 40) indicates critical cardiovascular compromise and
requires immediate hospitalization. While lanugo and amenorrhea are diagnostic signs,
they do not represent acute physiological instability. The nurse must prioritize vital signs
to prevent sudden cardiac arrest in eating disorder patients.
4. A patient with Borderline Personality Disorder (BPD) tells Nurse A, ‘You are the only one
who cares. Nurse B is so mean and incompetent.’ What is the nurse’s best response?
A. All nurses in this unit follow the same care plan for your safety.
B. I appreciate the compliment, but all our staff are well-trained.
C. It sounds like you are frustrated; let’s discuss your treatment plan.
D. I will talk to Nurse B and let her know you are upset.
Answer: A
Rationale: Splitting is a common defense mechanism in BPD where the patient views staff
as either ‘all good’ or ‘all bad.’ The nursing intervention must focus on consistent limit-
setting and maintaining a unified staff approach. By reinforcing the team care plan, the
nurse prevents manipulation and promotes milieu stability.
5. A patient is prescribed Donepezil (Aricept) for moderate Alzheimer’s disease. Which side
effect should the nurse instruct the family to monitor most closely?
A. Severe hypertension.
B. Extrapyramidal symptoms.
C. Syncope and bradycardia.
D. Urinary retention.
Answer: C
Rationale: Cholinesterase inhibitors like Donepezil enhance parasympathetic activity,
which can lead to bradycardia and syncope, increasing fall risks. Families must be educated
to monitor heart rate and ensure the environment is safe to prevent fractures. This is a vital
safety assessment in the geriatric population.
6. Which assessment finding would the nurse expect in a patient who has just ingested a high
dose of Cocaine?
A. Constricted pupils and drowsiness.
B. Hypotension and bradypnea.
C. Dilated pupils and tachycardia.
D. Increased appetite and hypersomnia.
, Answer: C
Rationale: Cocaine is a central nervous system stimulant that causes a sympathetic ‘fight
or flight’ response, including pupillary dilation and increased heart rate. The nurse must
monitor for cardiac arrhythmias and myocardial infarction during the intoxication phase.
Safety monitoring is paramount due to the high potential for agitation and violence.
7. A patient with Antisocial Personality Disorder is caught smoking in a non-smoking area.
The patient says, ‘I’ve had a bad day, just let it slide once.’ What is the nurse’s most
appropriate action?
A. Allow the patient to finish the cigarette to prevent escalation.
B. Explain the health risks of smoking to the patient.
C. Ignore the behavior unless the patient becomes aggressive.
D. Inform the patient that smoking is a violation of the rules and apply the agreed-upon
consequence.
Answer: D
Rationale: Consistent limit-setting is the primary intervention for patients with Antisocial
Personality Disorder who frequently challenge boundaries. Allowing exceptions reinforces
manipulative behavior and undermines the therapeutic milieu. Nurses must maintain
professional neutrality while enforcing unit rules to promote behavioral accountability.
8. In the ‘Refeeding’ phase for a patient with severe malnutrition, which laboratory value is
the most critical for the nurse to monitor?
A. Serum Potassium.
B. Blood Urea Nitrogen (BUN).
C. Serum Phosphate.
D. Hemoglobin A1c.
Answer: C
Rationale: Refeeding Syndrome is characterized by a dangerous drop in serum phosphate
as the body shifts from a catabolic to an anabolic state. Hypophosphatemia can lead to
cardiac failure, seizures, and respiratory distress. The nurse must monitor electrolytes
daily and advocate for slow reintroduction of nutrients.
9. A nurse is caring for a patient with Bulimia Nervosa. Which physical assessment finding is
most likely associated with the use of self-induced vomiting?
A. Development of a fine downy hair on the face.
B. High blood pressure.
C. Hypertrophy of the parotid glands.
