NUR 253 Exam 3 V1 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client experiencing a panic level of anxiety. Which action should the
nurse take first?
A. Teach the client deep breathing exercises.
B. Provide a quiet environment with low stimuli.
C. Ask the client to explain what triggered the anxiety.
D. Administer a scheduled dose of an antidepressant.
Correct Answer: B
Expert Explanation: In the panic stage of anxiety, the client is unable to process
information or learn new skills like deep breathing. Providing a calm, low-stimulus
environment is the priority to ensure safety and help the client feel secure. The nurse
should remain with the client and use short, simple sentences until the level of anxiety
decreases.
2. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day washing
their hands. What is the most appropriate initial nursing intervention?
A. Lock the bathroom door to prevent the behavior.
B. Explain the physical damage handwashing causes.
,C. Administer an antipsychotic medication immediately.
D. Allow the client extra time for the ritual initially.
Correct Answer: D
Expert Explanation: Initially, the nurse should allow the client time to perform rituals to
prevent a sudden increase in anxiety. Forcing a client to stop a ritual abruptly can lead to
panic and distress. Over time, the nurse will work with the client to set limits and develop
healthier coping mechanisms.
3. A client is diagnosed with Anorexia Nervosa. Which assessment finding is considered a
medical emergency?
A. Body Mass Index (BMI) of 17.5.
B. Client reports a fear of gaining weight.
C. Presence of fine lanugo hair on the back.
D. Potassium level of 2.8 mEq/L.
Correct Answer: D
Expert Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which
can lead to life-threatening cardiac arrhythmias. Electrolyte imbalances are a primary
concern in patients with eating disorders due to purging or starvation. While a low BMI and
lanugo are typical findings, they do not represent an immediate physiological crisis
compared to the potassium level.
, 4. Which behavior is most characteristic of a client with Borderline Personality Disorder?
A. Social withdrawal and lack of interest in relationships.
B. Grandiosity and a need for constant admiration.
C. Extreme perfectionism and preoccupation with order.
D. Impulsive actions and unstable interpersonal relationships.
Correct Answer: D
Expert Explanation: Borderline Personality Disorder is characterized by a pattern of
instability in emotions, self-image, and relationships. Clients often display impulsivity and
may engage in self-harming behaviors when feeling abandoned. They frequently use a
defense mechanism called splitting, where they see people as all good or all bad.
5. A nurse is assessing a client for suspected alcohol withdrawal. Which symptom should the
nurse expect to find first?
A. Fine tremors of the hands.
B. Auditory hallucinations.
C. Generalized tonic-clonic seizures.
D. Profuse diaphoresis and hypertension.
Correct Answer: A
Expert Explanation: Fine tremors of the hands are one of the earliest signs of alcohol
withdrawal, typically occurring within 6 to 8 hours after the last drink. Other early
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client experiencing a panic level of anxiety. Which action should the
nurse take first?
A. Teach the client deep breathing exercises.
B. Provide a quiet environment with low stimuli.
C. Ask the client to explain what triggered the anxiety.
D. Administer a scheduled dose of an antidepressant.
Correct Answer: B
Expert Explanation: In the panic stage of anxiety, the client is unable to process
information or learn new skills like deep breathing. Providing a calm, low-stimulus
environment is the priority to ensure safety and help the client feel secure. The nurse
should remain with the client and use short, simple sentences until the level of anxiety
decreases.
2. A client with Obsessive-Compulsive Disorder (OCD) spends several hours a day washing
their hands. What is the most appropriate initial nursing intervention?
A. Lock the bathroom door to prevent the behavior.
B. Explain the physical damage handwashing causes.
,C. Administer an antipsychotic medication immediately.
D. Allow the client extra time for the ritual initially.
Correct Answer: D
Expert Explanation: Initially, the nurse should allow the client time to perform rituals to
prevent a sudden increase in anxiety. Forcing a client to stop a ritual abruptly can lead to
panic and distress. Over time, the nurse will work with the client to set limits and develop
healthier coping mechanisms.
3. A client is diagnosed with Anorexia Nervosa. Which assessment finding is considered a
medical emergency?
A. Body Mass Index (BMI) of 17.5.
B. Client reports a fear of gaining weight.
C. Presence of fine lanugo hair on the back.
D. Potassium level of 2.8 mEq/L.
Correct Answer: D
Expert Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which
can lead to life-threatening cardiac arrhythmias. Electrolyte imbalances are a primary
concern in patients with eating disorders due to purging or starvation. While a low BMI and
lanugo are typical findings, they do not represent an immediate physiological crisis
compared to the potassium level.
, 4. Which behavior is most characteristic of a client with Borderline Personality Disorder?
A. Social withdrawal and lack of interest in relationships.
B. Grandiosity and a need for constant admiration.
C. Extreme perfectionism and preoccupation with order.
D. Impulsive actions and unstable interpersonal relationships.
Correct Answer: D
Expert Explanation: Borderline Personality Disorder is characterized by a pattern of
instability in emotions, self-image, and relationships. Clients often display impulsivity and
may engage in self-harming behaviors when feeling abandoned. They frequently use a
defense mechanism called splitting, where they see people as all good or all bad.
5. A nurse is assessing a client for suspected alcohol withdrawal. Which symptom should the
nurse expect to find first?
A. Fine tremors of the hands.
B. Auditory hallucinations.
C. Generalized tonic-clonic seizures.
D. Profuse diaphoresis and hypertension.
Correct Answer: A
Expert Explanation: Fine tremors of the hands are one of the earliest signs of alcohol
withdrawal, typically occurring within 6 to 8 hours after the last drink. Other early
