NSG221/NSG 221 Exam 4 V1 | Mental
Health Nursing Q&A with Rationale |
Herzing University
1. A nurse is assessing a 75-year-old client who was recently admitted for a urinary tract
infection and is now experiencing sudden confusion and fluctuating levels of consciousness.
Which condition should the nurse suspect?
A. Alzheimer’s Disease
B. Vascular Dementia
C. Depression
D. Delirium
Correct Answer: D
Rationale: Delirium is characterized by an acute onset and fluctuating course of
consciousness and cognition, often triggered by an underlying medical condition like a UTI.
Unlike dementia, delirium is generally reversible once the primary cause is treated. The
nurse must prioritize immediate medical assessment to identify and treat the physiological
stressor.
2. A client with late-stage Alzheimer’s disease is unable to recognize familiar objects, such as
a hairbrush or a spoon. Which term should the nurse use to document this finding?
A. Agnosia
,B. Aphasia
C. Apraxia
D. Anomia
Correct Answer: A
Rationale: Agnosia is the inability to recognize or identify objects or people despite intact
sensory function. This symptom is common as neurocognitive decline progresses in
Alzheimer’s patients. Identifying these specific deficits helps the nursing team adjust the
care plan to ensure safety and provide appropriate assistance with activities of daily living.
3. The nurse is preparing to administer donepezil (Aricept) to a client with mild-to-moderate
Alzheimer’s disease. Which side effect is the priority for the nurse to monitor?
A. Hypertension
B. Constipation
C. Tachycardia
D. Bradycardia
Correct Answer: D
Rationale: Donepezil is a cholinesterase inhibitor that increases acetylcholine levels, which
can lead to parasympathetic effects like bradycardia and syncope. Clients taking this
medication are at an increased risk for falls due to potential heart rate changes. The nurse
,should assess the pulse regularly and educate the family on monitoring for dizziness or
fainting spells.
4. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
symptoms should the nurse identify as a manifestation of delirium tremens (DTs)?
A. Hypotension and bradycardia
B. Visual hallucinations and diaphoresis
C. Somnolence and clear speech
D. Normal body temperature
Correct Answer: B
Rationale: Delirium tremens is a severe form of alcohol withdrawal characterized by
autonomic hyperactivity, including tachycardia, diaphoresis, and hypertension, along with
vivid visual or tactile hallucinations. This is a medical emergency that usually occurs 48 to
72 hours after the last drink. Nursing interventions must focus on seizure precautions and
aggressive pharmacological management with benzodiazepines.
5. A client is prescribed disulfiram (Antabuse) for alcohol use disorder. Which instruction is
most important for the nurse to include in the teaching?
A. You should take this medication only when you feel an urge to drink.
B. The medication will stop the cravings for alcohol immediately.
C. It is safe to drink one glass of wine while on this medication.
, D. Avoid all products containing alcohol, including mouthwash and vanilla extract.
Correct Answer: D
Rationale: Disulfiram works by causing a severe physical reaction when even small
amounts of alcohol are ingested, known as the disulfiram-alcohol reaction. This reaction
can cause pounding chest pain, severe vomiting, and hypotension. The nurse must
emphasize that the client needs to read labels carefully to avoid hidden alcohol in everyday
products to prevent life-threatening symptoms.
6. A client with Borderline Personality Disorder (BPD) tells the day-shift nurse, ‘The night
nurse is so mean, but you are the only one who truly understands me.’ This is an example of:
A. Altruism
B. Rationalization
C. Sublimation
D. Splitting
Correct Answer: D
Rationale: Splitting is a common defense mechanism in individuals with BPD where they
perceive people as either all good or all bad. This behavior often leads to conflict within the
healthcare team as the client attempts to pit staff members against each other. The nursing
staff must maintain consistent communication and a united front to manage this behavior
effectively.
Health Nursing Q&A with Rationale |
Herzing University
1. A nurse is assessing a 75-year-old client who was recently admitted for a urinary tract
infection and is now experiencing sudden confusion and fluctuating levels of consciousness.
Which condition should the nurse suspect?
A. Alzheimer’s Disease
B. Vascular Dementia
C. Depression
D. Delirium
Correct Answer: D
Rationale: Delirium is characterized by an acute onset and fluctuating course of
consciousness and cognition, often triggered by an underlying medical condition like a UTI.
Unlike dementia, delirium is generally reversible once the primary cause is treated. The
nurse must prioritize immediate medical assessment to identify and treat the physiological
stressor.
2. A client with late-stage Alzheimer’s disease is unable to recognize familiar objects, such as
a hairbrush or a spoon. Which term should the nurse use to document this finding?
A. Agnosia
,B. Aphasia
C. Apraxia
D. Anomia
Correct Answer: A
Rationale: Agnosia is the inability to recognize or identify objects or people despite intact
sensory function. This symptom is common as neurocognitive decline progresses in
Alzheimer’s patients. Identifying these specific deficits helps the nursing team adjust the
care plan to ensure safety and provide appropriate assistance with activities of daily living.
3. The nurse is preparing to administer donepezil (Aricept) to a client with mild-to-moderate
Alzheimer’s disease. Which side effect is the priority for the nurse to monitor?
A. Hypertension
B. Constipation
C. Tachycardia
D. Bradycardia
Correct Answer: D
Rationale: Donepezil is a cholinesterase inhibitor that increases acetylcholine levels, which
can lead to parasympathetic effects like bradycardia and syncope. Clients taking this
medication are at an increased risk for falls due to potential heart rate changes. The nurse
,should assess the pulse regularly and educate the family on monitoring for dizziness or
fainting spells.
4. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
symptoms should the nurse identify as a manifestation of delirium tremens (DTs)?
A. Hypotension and bradycardia
B. Visual hallucinations and diaphoresis
C. Somnolence and clear speech
D. Normal body temperature
Correct Answer: B
Rationale: Delirium tremens is a severe form of alcohol withdrawal characterized by
autonomic hyperactivity, including tachycardia, diaphoresis, and hypertension, along with
vivid visual or tactile hallucinations. This is a medical emergency that usually occurs 48 to
72 hours after the last drink. Nursing interventions must focus on seizure precautions and
aggressive pharmacological management with benzodiazepines.
5. A client is prescribed disulfiram (Antabuse) for alcohol use disorder. Which instruction is
most important for the nurse to include in the teaching?
A. You should take this medication only when you feel an urge to drink.
B. The medication will stop the cravings for alcohol immediately.
C. It is safe to drink one glass of wine while on this medication.
, D. Avoid all products containing alcohol, including mouthwash and vanilla extract.
Correct Answer: D
Rationale: Disulfiram works by causing a severe physical reaction when even small
amounts of alcohol are ingested, known as the disulfiram-alcohol reaction. This reaction
can cause pounding chest pain, severe vomiting, and hypotension. The nurse must
emphasize that the client needs to read labels carefully to avoid hidden alcohol in everyday
products to prevent life-threatening symptoms.
6. A client with Borderline Personality Disorder (BPD) tells the day-shift nurse, ‘The night
nurse is so mean, but you are the only one who truly understands me.’ This is an example of:
A. Altruism
B. Rationalization
C. Sublimation
D. Splitting
Correct Answer: D
Rationale: Splitting is a common defense mechanism in individuals with BPD where they
perceive people as either all good or all bad. This behavior often leads to conflict within the
healthcare team as the client attempts to pit staff members against each other. The nursing
staff must maintain consistent communication and a united front to manage this behavior
effectively.
