NUR 253 Exam 4 Actual Exam V2 | NUR 253 Mental Health Nursing
(NUR253 Exam 4) | Galen College of Nursing
1. A nurse is caring for a client with delirium. Which assessment finding is most characteristic
of this disorder?
A. Gradual onset of memory loss over several years
B. Stable mood with no changes in sleep-wake cycles
C. Fluctuating levels of consciousness throughout the day
D. Intact abstract thinking despite disorientation
Answer: C
Rationale: Delirium is characterized by an acute onset and a fluctuating course of
consciousness and cognition. Unlike dementia, which is stable and progressive, delirium
symptoms often worsen at night, known as sundowning. This condition is considered a
medical emergency and requires immediate identification of the underlying cause.
2. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate the provider will order to manage acute withdrawal symptoms?
A. Disulfiram
B. Methadone
C. Chlordiazepoxide
D. Varenicline
Answer: C
Rationale: Benzodiazepines like chlordiazepoxide are the gold standard for managing
acute alcohol withdrawal to prevent seizures and delirium tremens. Disulfiram is used for
maintenance of sobriety but can be dangerous if used during active withdrawal. The nurse
must monitor the client’s CIWA score to determine the appropriate dosage frequency.
3. The nurse is assessing a client with Anorexia Nervosa. Which finding would necessitate
immediate hospitalization?
A. Body mass index (BMI) of 18
B. Refusal to participate in group therapy
C. Potassium level of 3.8 mEq/L
D. Heart rate of 38 beats per minute
Answer: D
,Rationale: Severe bradycardia (less than 40 bpm) is a critical indicator of cardiac
instability in clients with eating disorders. Hospitalization is required when physiological
parameters such as heart rate, blood pressure, or electrolyte balance reach life-threatening
levels. A potassium level of 3.8 is within normal limits, and a BMI of 18 is underweight but
not necessarily an acute emergency.
4. A client with Borderline Personality Disorder (BPD) tells the night shift nurse, ‘The day
nurse is terrible, but you are the only one who understands me.’ This is an example of:
A. Idealization
B. Reaction Formation
C. Projection
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the individual
perceives others as either ‘all good’ or ‘all bad.’ This behavior creates conflict among the
healthcare team and is used to manipulate the environment. The nurse should maintain
consistent boundaries and communicate with the rest of the staff to ensure a unified
treatment approach.
5. Which intervention is the priority for a nurse when caring for a client experiencing a panic-
level of anxiety?
A. Teaching the client new relaxation techniques
B. Leaving the client alone to reduce stimulation
C. Asking the client to explain the trigger for their anxiety
D. Staying with the client and using short, simple sentences
Answer: D
Rationale: In a panic state, the client is unable to process complex information or learn
new skills. The nurse’s priority is safety and providing a calm, non-threatening presence.
Using short, simple sentences helps the client understand directions while the nurse
remains present to ensure the client does not harm themselves.
6. A client has been prescribed Lithium Carbonate for Bipolar I Disorder. Which statement by
the client indicates a need for further teaching?
A. I should drink 2 to 3 liters of fluid every day.
B. I will make sure to keep my salt intake consistent.
C. I need to have my blood levels checked regularly.
D. I will take a diuretic if I notice any swelling in my ankles.
, Answer: D
Rationale: Diuretics increase the risk of lithium toxicity by causing sodium depletion,
which leads the kidneys to reabsorb lithium. Clients must maintain a stable intake of salt
and water to keep lithium levels within the therapeutic range. Any over-the-counter
medications, especially diuretics or NSAIDs, should be cleared by the provider first.
7. A nurse is evaluating a child with ADHD who was recently started on Methylphenidate.
Which side effect should the nurse monitor for most closely?
A. Weight gain and increased appetite
B. Excessive sleepiness and lethargy
C. Bradycardia and hypotension
D. Insomnia and growth suppression
Answer: D
Rationale: Methylphenidate is a central nervous system stimulant that commonly causes
insomnia and appetite suppression, which can lead to delayed growth in children. Nurses
should monitor the child’s height and weight regularly during therapy. Administering the
medication earlier in the day can help mitigate difficulties with falling asleep.
8. A nurse suspects that an older adult client is being neglected by their caregiver. What is the
nurse’s first legal responsibility?
A. Confront the caregiver about the suspected neglect
B. Report the findings to the appropriate state agency
C. Wait until there is definitive proof before taking action
D. Discuss the situation with the client’s family first
Answer: B
Rationale: Nurses are mandated reporters for suspected abuse or neglect of vulnerable
populations, including children and the elderly. The nurse does not need definitive proof,
only a reasonable suspicion based on assessment. Reporting ensures that a formal
investigation can protect the client from further harm.
9. An adolescent with Conduct Disorder is aggressive toward a peer. Which nursing action is
most appropriate?
A. Set firm limits and provide immediate consequences
B. Explain why the behavior is harmful in a long discussion
C. Offer a reward to stop the aggressive behavior
D. Ignore the behavior to avoid giving it attention
(NUR253 Exam 4) | Galen College of Nursing
1. A nurse is caring for a client with delirium. Which assessment finding is most characteristic
of this disorder?
A. Gradual onset of memory loss over several years
B. Stable mood with no changes in sleep-wake cycles
C. Fluctuating levels of consciousness throughout the day
D. Intact abstract thinking despite disorientation
Answer: C
Rationale: Delirium is characterized by an acute onset and a fluctuating course of
consciousness and cognition. Unlike dementia, which is stable and progressive, delirium
symptoms often worsen at night, known as sundowning. This condition is considered a
medical emergency and requires immediate identification of the underlying cause.
2. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate the provider will order to manage acute withdrawal symptoms?
A. Disulfiram
B. Methadone
C. Chlordiazepoxide
D. Varenicline
Answer: C
Rationale: Benzodiazepines like chlordiazepoxide are the gold standard for managing
acute alcohol withdrawal to prevent seizures and delirium tremens. Disulfiram is used for
maintenance of sobriety but can be dangerous if used during active withdrawal. The nurse
must monitor the client’s CIWA score to determine the appropriate dosage frequency.
3. The nurse is assessing a client with Anorexia Nervosa. Which finding would necessitate
immediate hospitalization?
A. Body mass index (BMI) of 18
B. Refusal to participate in group therapy
C. Potassium level of 3.8 mEq/L
D. Heart rate of 38 beats per minute
Answer: D
,Rationale: Severe bradycardia (less than 40 bpm) is a critical indicator of cardiac
instability in clients with eating disorders. Hospitalization is required when physiological
parameters such as heart rate, blood pressure, or electrolyte balance reach life-threatening
levels. A potassium level of 3.8 is within normal limits, and a BMI of 18 is underweight but
not necessarily an acute emergency.
4. A client with Borderline Personality Disorder (BPD) tells the night shift nurse, ‘The day
nurse is terrible, but you are the only one who understands me.’ This is an example of:
A. Idealization
B. Reaction Formation
C. Projection
D. Splitting
Answer: D
Rationale: Splitting is a common defense mechanism in BPD where the individual
perceives others as either ‘all good’ or ‘all bad.’ This behavior creates conflict among the
healthcare team and is used to manipulate the environment. The nurse should maintain
consistent boundaries and communicate with the rest of the staff to ensure a unified
treatment approach.
5. Which intervention is the priority for a nurse when caring for a client experiencing a panic-
level of anxiety?
A. Teaching the client new relaxation techniques
B. Leaving the client alone to reduce stimulation
C. Asking the client to explain the trigger for their anxiety
D. Staying with the client and using short, simple sentences
Answer: D
Rationale: In a panic state, the client is unable to process complex information or learn
new skills. The nurse’s priority is safety and providing a calm, non-threatening presence.
Using short, simple sentences helps the client understand directions while the nurse
remains present to ensure the client does not harm themselves.
6. A client has been prescribed Lithium Carbonate for Bipolar I Disorder. Which statement by
the client indicates a need for further teaching?
A. I should drink 2 to 3 liters of fluid every day.
B. I will make sure to keep my salt intake consistent.
C. I need to have my blood levels checked regularly.
D. I will take a diuretic if I notice any swelling in my ankles.
, Answer: D
Rationale: Diuretics increase the risk of lithium toxicity by causing sodium depletion,
which leads the kidneys to reabsorb lithium. Clients must maintain a stable intake of salt
and water to keep lithium levels within the therapeutic range. Any over-the-counter
medications, especially diuretics or NSAIDs, should be cleared by the provider first.
7. A nurse is evaluating a child with ADHD who was recently started on Methylphenidate.
Which side effect should the nurse monitor for most closely?
A. Weight gain and increased appetite
B. Excessive sleepiness and lethargy
C. Bradycardia and hypotension
D. Insomnia and growth suppression
Answer: D
Rationale: Methylphenidate is a central nervous system stimulant that commonly causes
insomnia and appetite suppression, which can lead to delayed growth in children. Nurses
should monitor the child’s height and weight regularly during therapy. Administering the
medication earlier in the day can help mitigate difficulties with falling asleep.
8. A nurse suspects that an older adult client is being neglected by their caregiver. What is the
nurse’s first legal responsibility?
A. Confront the caregiver about the suspected neglect
B. Report the findings to the appropriate state agency
C. Wait until there is definitive proof before taking action
D. Discuss the situation with the client’s family first
Answer: B
Rationale: Nurses are mandated reporters for suspected abuse or neglect of vulnerable
populations, including children and the elderly. The nurse does not need definitive proof,
only a reasonable suspicion based on assessment. Reporting ensures that a formal
investigation can protect the client from further harm.
9. An adolescent with Conduct Disorder is aggressive toward a peer. Which nursing action is
most appropriate?
A. Set firm limits and provide immediate consequences
B. Explain why the behavior is harmful in a long discussion
C. Offer a reward to stop the aggressive behavior
D. Ignore the behavior to avoid giving it attention
