NUR 256 Exam 3 V1 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a client with suspected delirium. Which finding would support this
diagnosis rather than dementia?
A. The client has a slow, progressive decline in cognitive function over several years.
B. The client’s level of consciousness fluctuates throughout the day and is worse at night.
C. The client’s memory loss is permanent and irreversible regardless of treatment.
D. The client remains oriented to person and place despite having short-term memory
deficits.
Answer: B
Rationale: Delirium is characterized by an acute onset and a fluctuating level of
consciousness. Unlike dementia, which is progressive and stable, delirium often presents
with disturbances in sleep-wake cycles and worsened symptoms at night. Identifying these
fluctuations is essential for addressing the underlying medical cause of the delirium.
2. A client admitted for alcohol withdrawal is experiencing coarse hand tremors, tachycardia,
and hypertension. Which medication should the nurse expect to administer?
A. Chlordiazepoxide
,B. Methadone
C. Disulfiram
D. Naloxone
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent or manage the symptoms
of alcohol withdrawal. These medications help stabilize vital signs and reduce the risk of
withdrawal-related seizures. The nurse must monitor the client closely for respiratory
depression and sedation after administration.
3. An adolescent client with anorexia nervosa is being admitted to the inpatient unit. Which
assessment finding requires immediate nursing intervention?
A. A heart rate of 38 beats per minute and hypotension.
B. The presence of lanugo on the back and extremities.
C. The client reporting a fear of gaining weight.
D. A serum potassium level of 3.6 mEq/L.
Answer: A
Rationale: Severe bradycardia and hypotension are clinical indicators of physiological
instability in clients with anorexia nervosa. These findings suggest the body is in a state of
starvation and may lead to cardiac arrest. The nurse must prioritize cardiovascular
monitoring and stabilization over psychological interventions in this acute phase.
, 4. A nurse is caring for a client with borderline personality disorder who is using ‘splitting’
behavior. What is the most appropriate nursing action?
A. Allowing the client to select which nurse they want to work with during the shift.
B. Communicating and maintaining consistent limits among all members of the treatment
team.
C. Confronting the client about their behavior during a group therapy session.
D. Ignoring the behavior to avoid giving the client positive reinforcement for manipulation.
Answer: B
Rationale: Splitting is a defense mechanism where the client views individuals as either all
good or all bad. Consistency among the nursing staff is vital to prevent the client from
playing one staff member against another. Clear communication and limit-setting help
maintain a therapeutic and safe environment for all clients.
5. Which pharmacological intervention is considered the first-line treatment for a child
diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD)?
A. Lithium carbonate
B. Haloperidol
C. Methylphenidate
D. Fluoxetine
Answer: C
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a client with suspected delirium. Which finding would support this
diagnosis rather than dementia?
A. The client has a slow, progressive decline in cognitive function over several years.
B. The client’s level of consciousness fluctuates throughout the day and is worse at night.
C. The client’s memory loss is permanent and irreversible regardless of treatment.
D. The client remains oriented to person and place despite having short-term memory
deficits.
Answer: B
Rationale: Delirium is characterized by an acute onset and a fluctuating level of
consciousness. Unlike dementia, which is progressive and stable, delirium often presents
with disturbances in sleep-wake cycles and worsened symptoms at night. Identifying these
fluctuations is essential for addressing the underlying medical cause of the delirium.
2. A client admitted for alcohol withdrawal is experiencing coarse hand tremors, tachycardia,
and hypertension. Which medication should the nurse expect to administer?
A. Chlordiazepoxide
,B. Methadone
C. Disulfiram
D. Naloxone
Answer: A
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent or manage the symptoms
of alcohol withdrawal. These medications help stabilize vital signs and reduce the risk of
withdrawal-related seizures. The nurse must monitor the client closely for respiratory
depression and sedation after administration.
3. An adolescent client with anorexia nervosa is being admitted to the inpatient unit. Which
assessment finding requires immediate nursing intervention?
A. A heart rate of 38 beats per minute and hypotension.
B. The presence of lanugo on the back and extremities.
C. The client reporting a fear of gaining weight.
D. A serum potassium level of 3.6 mEq/L.
Answer: A
Rationale: Severe bradycardia and hypotension are clinical indicators of physiological
instability in clients with anorexia nervosa. These findings suggest the body is in a state of
starvation and may lead to cardiac arrest. The nurse must prioritize cardiovascular
monitoring and stabilization over psychological interventions in this acute phase.
, 4. A nurse is caring for a client with borderline personality disorder who is using ‘splitting’
behavior. What is the most appropriate nursing action?
A. Allowing the client to select which nurse they want to work with during the shift.
B. Communicating and maintaining consistent limits among all members of the treatment
team.
C. Confronting the client about their behavior during a group therapy session.
D. Ignoring the behavior to avoid giving the client positive reinforcement for manipulation.
Answer: B
Rationale: Splitting is a defense mechanism where the client views individuals as either all
good or all bad. Consistency among the nursing staff is vital to prevent the client from
playing one staff member against another. Clear communication and limit-setting help
maintain a therapeutic and safe environment for all clients.
5. Which pharmacological intervention is considered the first-line treatment for a child
diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD)?
A. Lithium carbonate
B. Haloperidol
C. Methylphenidate
D. Fluoxetine
Answer: C
