NUR 253 Exam 4 V2 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is using splitting
behavior. Which action should the nurse take?
A. Hold a staff meeting to ensure a consistent approach.
B. Allow the client to choose which nurse they work with.
C. Ignore the behavior to avoid reinforcing it.
D. Discuss the client’s behavior with other patients.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views staff as
either all good or all bad, which can cause conflict among the care team. Holding regular
staff meetings ensures that all team members are on the same page and providing
consistent care. This approach prevents the client from manipulating staff and maintains
professional boundaries.
2. Which physical assessment finding is most characteristic of a client with severe Anorexia
Nervosa?
A. Hypertension
B. Lanugo
,C. Tachycardia
D. Hyperthermia
Correct Answer: B
Expert Explanation: Lanugo is the growth of fine, downy hair on the body as a
physiological response to extreme malnutrition and loss of body fat. It serves as an attempt
by the body to provide insulation and maintain heat in the absence of subcutaneous fat.
Other signs typically include bradycardia and hypotension rather than tachycardia and
hypertension.
3. A client is prescribed Donepezil for Alzheimer’s disease. What is the primary purpose of
this medication?
A. To cure the underlying neurodegeneration.
B. To improve cognitive function by increasing acetylcholine.
C. To reverse the loss of memory.
D. To sedate the client during periods of agitation.
Correct Answer: B
Expert Explanation: Donepezil is a cholinesterase inhibitor that works by preventing the
breakdown of acetylcholine in the brain. This can help improve or stabilize cognitive
function and daily living activities in clients with mild to moderate Alzheimer’s. It is
important to note that the drug does not cure the disease but manages symptoms.
, 4. A nurse is assessing a child with ADHD who has been taking methylphenidate. Which side
effect should be the priority to monitor?
A. Increased appetite
B. Lowered heart rate
C. Excessive sleepiness
D. Weight loss
Correct Answer: D
Expert Explanation: Methylphenidate is a stimulant that commonly causes appetite
suppression, which can lead to significant weight loss and growth suppression in children.
The nurse should monitor the child’s height and weight regularly to ensure they remain on
their growth curve. Administering the medication after meals can sometimes help mitigate
this effect.
5. A client with Antisocial Personality Disorder is being manipulative toward the staff. What is
the most appropriate nursing intervention?
A. Provide the client with extra privileges to build rapport.
B. Let the client decide the unit rules for the day.
C. Set clear, consistent limits on behavior.
D. Avoid interacting with the client entirely.
Correct Answer: C
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is using splitting
behavior. Which action should the nurse take?
A. Hold a staff meeting to ensure a consistent approach.
B. Allow the client to choose which nurse they work with.
C. Ignore the behavior to avoid reinforcing it.
D. Discuss the client’s behavior with other patients.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views staff as
either all good or all bad, which can cause conflict among the care team. Holding regular
staff meetings ensures that all team members are on the same page and providing
consistent care. This approach prevents the client from manipulating staff and maintains
professional boundaries.
2. Which physical assessment finding is most characteristic of a client with severe Anorexia
Nervosa?
A. Hypertension
B. Lanugo
,C. Tachycardia
D. Hyperthermia
Correct Answer: B
Expert Explanation: Lanugo is the growth of fine, downy hair on the body as a
physiological response to extreme malnutrition and loss of body fat. It serves as an attempt
by the body to provide insulation and maintain heat in the absence of subcutaneous fat.
Other signs typically include bradycardia and hypotension rather than tachycardia and
hypertension.
3. A client is prescribed Donepezil for Alzheimer’s disease. What is the primary purpose of
this medication?
A. To cure the underlying neurodegeneration.
B. To improve cognitive function by increasing acetylcholine.
C. To reverse the loss of memory.
D. To sedate the client during periods of agitation.
Correct Answer: B
Expert Explanation: Donepezil is a cholinesterase inhibitor that works by preventing the
breakdown of acetylcholine in the brain. This can help improve or stabilize cognitive
function and daily living activities in clients with mild to moderate Alzheimer’s. It is
important to note that the drug does not cure the disease but manages symptoms.
, 4. A nurse is assessing a child with ADHD who has been taking methylphenidate. Which side
effect should be the priority to monitor?
A. Increased appetite
B. Lowered heart rate
C. Excessive sleepiness
D. Weight loss
Correct Answer: D
Expert Explanation: Methylphenidate is a stimulant that commonly causes appetite
suppression, which can lead to significant weight loss and growth suppression in children.
The nurse should monitor the child’s height and weight regularly to ensure they remain on
their growth curve. Administering the medication after meals can sometimes help mitigate
this effect.
5. A client with Antisocial Personality Disorder is being manipulative toward the staff. What is
the most appropriate nursing intervention?
A. Provide the client with extra privileges to build rapport.
B. Let the client decide the unit rules for the day.
C. Set clear, consistent limits on behavior.
D. Avoid interacting with the client entirely.
Correct Answer: C
