NUR 253 Exam 4 V3 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse expect to administer first?
A. Quetiapine
B. Disulfiram
C. Fluoxetine
D. Chlordiazepoxide
Correct Answer: D
Expert Explanation: Chlordiazepoxide is a benzodiazepine used to manage alcohol
withdrawal symptoms by providing cross-tolerance. It helps prevent seizures and delirium
tremens during the detoxification process. The nurse must monitor the client closely for
respiratory depression and sedation after administration.
2. Which assessment finding is most critical for a nurse to address in a client diagnosed with
Anorexia Nervosa?
A. Weight 20% below ideal body weight
B. Presence of lanugo on the back and arms
,C. Potassium level of 2.9 mEq/L
D. Amenorrhea for the past six months
Correct Answer: C
Expert Explanation: A potassium level of 2.9 mEq/L indicates significant hypokalemia,
which can lead to life-threatening cardiac dysrhythmias. While weight loss and lanugo are
classic signs of anorexia, electrolyte imbalances pose an immediate physiological threat.
The nurse should prioritize cardiac monitoring and electrolyte replacement therapy.
3. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily washing their
hands. What is the primary nursing goal during the initial phase of treatment?
A. Immediately stop the ritualistic hand-washing behavior
B. Challenge the client’s irrational thoughts about germs
C. Allow the client to continue rituals to manage anxiety
D. Provide the client with a list of alternative hobbies
Correct Answer: C
Expert Explanation: In the initial phase of OCD treatment, the nurse should allow the
client to perform rituals because preventing them can cause a panic level of anxiety. The
goal is to gradually reduce the time spent on rituals through cognitive-behavioral
techniques later on. Forcing a sudden stop can be detrimental to the therapeutic
relationship and the client’s stability.
, 4. A child is prescribed methylphenidate for ADHD. Which instruction should the nurse
include in the teaching plan for the parents?
A. Monitor the child’s height and weight regularly
B. Administer the medication right before bedtime
C. Expect the child to have an increased appetite
D. The medication should be taken on an empty stomach
Correct Answer: A
Expert Explanation: Methylphenidate is a stimulant that can cause weight loss and growth
suppression in children. Parents should track growth patterns and report significant
deviations to the healthcare provider. Additionally, the medication is usually given in the
morning to avoid insomnia and with meals to minimize gastrointestinal upset.
5. A nurse is caring for a client with Bulimia Nervosa. Which physical finding is most
characteristic of this disorder?
A. Extreme bradycardia and hypotension
B. Dental caries and erosion of tooth enamel
C. Yellowish skin tone from hypercarotenemia
D. Prominent bones and lack of subcutaneous fat
Correct Answer: B
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse expect to administer first?
A. Quetiapine
B. Disulfiram
C. Fluoxetine
D. Chlordiazepoxide
Correct Answer: D
Expert Explanation: Chlordiazepoxide is a benzodiazepine used to manage alcohol
withdrawal symptoms by providing cross-tolerance. It helps prevent seizures and delirium
tremens during the detoxification process. The nurse must monitor the client closely for
respiratory depression and sedation after administration.
2. Which assessment finding is most critical for a nurse to address in a client diagnosed with
Anorexia Nervosa?
A. Weight 20% below ideal body weight
B. Presence of lanugo on the back and arms
,C. Potassium level of 2.9 mEq/L
D. Amenorrhea for the past six months
Correct Answer: C
Expert Explanation: A potassium level of 2.9 mEq/L indicates significant hypokalemia,
which can lead to life-threatening cardiac dysrhythmias. While weight loss and lanugo are
classic signs of anorexia, electrolyte imbalances pose an immediate physiological threat.
The nurse should prioritize cardiac monitoring and electrolyte replacement therapy.
3. A client with Obsessive-Compulsive Disorder (OCD) spends two hours daily washing their
hands. What is the primary nursing goal during the initial phase of treatment?
A. Immediately stop the ritualistic hand-washing behavior
B. Challenge the client’s irrational thoughts about germs
C. Allow the client to continue rituals to manage anxiety
D. Provide the client with a list of alternative hobbies
Correct Answer: C
Expert Explanation: In the initial phase of OCD treatment, the nurse should allow the
client to perform rituals because preventing them can cause a panic level of anxiety. The
goal is to gradually reduce the time spent on rituals through cognitive-behavioral
techniques later on. Forcing a sudden stop can be detrimental to the therapeutic
relationship and the client’s stability.
, 4. A child is prescribed methylphenidate for ADHD. Which instruction should the nurse
include in the teaching plan for the parents?
A. Monitor the child’s height and weight regularly
B. Administer the medication right before bedtime
C. Expect the child to have an increased appetite
D. The medication should be taken on an empty stomach
Correct Answer: A
Expert Explanation: Methylphenidate is a stimulant that can cause weight loss and growth
suppression in children. Parents should track growth patterns and report significant
deviations to the healthcare provider. Additionally, the medication is usually given in the
morning to avoid insomnia and with meals to minimize gastrointestinal upset.
5. A nurse is caring for a client with Bulimia Nervosa. Which physical finding is most
characteristic of this disorder?
A. Extreme bradycardia and hypotension
B. Dental caries and erosion of tooth enamel
C. Yellowish skin tone from hypercarotenemia
D. Prominent bones and lack of subcutaneous fat
Correct Answer: B
