NSG 322/NSG322 Exam 4 V3 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is assessing a client with delirium. Which of the following findings is most
characteristic of this condition?
A. Slow, progressive loss of memory and cognitive function
B. Rapid onset of confusion with fluctuating levels of consciousness
C. Relatively stable level of consciousness throughout the day
D. Absence of physiological triggers for mental status changes
Answer: B
Rationale: Delirium is characterized by an acute onset of confusion and a clouded
sensorium that typically fluctuates during the day. It is often secondary to an underlying
medical condition, such as an infection, dehydration, or medication toxicity. Nursing care
prioritizes identifying the cause and ensuring the client remains safe during the episode.
2. Which medication is most likely to be prescribed to prevent Wernicke-Korsakoff syndrome
in a client with chronic alcohol use disorder?
A. Lorazepam
B. Naloxone
C. Disulfiram
,D. Thiamine (Vitamin B1)
Answer: D
Rationale: Thiamine is essential for glucose metabolism in the brain, and chronic alcohol
use often leads to severe deficiency due to malabsorption. Wernicke-Korsakoff syndrome
involves serious neurological complications, including ataxia and ocular abnormalities.
Early supplementation is critical to prevent permanent cognitive impairment and
neurological damage.
3. A client diagnosed with anorexia nervosa is admitted to the unit. Which physical
assessment finding should the nurse anticipate?
A. Tachycardia and hypertension
B. Hyperthermia and moist skin
C. Hyperkalemia and metabolic acidosis
D. Lanugo and bradycardia
Answer: D
Rationale: Lanugo, which is fine, downy hair, is the body’s attempt to provide insulation in
the absence of subcutaneous fat. Bradycardia and hypotension occur as the body slows its
metabolic rate to conserve energy. These physiological changes are indicative of severe
malnutrition and require close medical monitoring.
, 4. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse respond?
A. Agree with the client’s assessment of other staff members to build rapport
B. Allow the client to choose which nurse provides care each shift
C. Maintain consistent boundaries and communicate clearly with the multidisciplinary
team
D. Ignore the behavior to avoid reinforcing the client’s manipulation
Answer: C
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad. Consistency among staff is vital to prevent the client from playing team members
against each other. Frequent team meetings and adherence to the care plan are necessary
to maintain a therapeutic environment.
5. A child with ADHD is prescribed methylphenidate. Which side effect should the nurse
instruct the parents to monitor?
A. Weight loss and insomnia
B. Excessive sleepiness during the day
C. Increased appetite and weight gain
D. Bradycardia and hypotension
Answer: A
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is assessing a client with delirium. Which of the following findings is most
characteristic of this condition?
A. Slow, progressive loss of memory and cognitive function
B. Rapid onset of confusion with fluctuating levels of consciousness
C. Relatively stable level of consciousness throughout the day
D. Absence of physiological triggers for mental status changes
Answer: B
Rationale: Delirium is characterized by an acute onset of confusion and a clouded
sensorium that typically fluctuates during the day. It is often secondary to an underlying
medical condition, such as an infection, dehydration, or medication toxicity. Nursing care
prioritizes identifying the cause and ensuring the client remains safe during the episode.
2. Which medication is most likely to be prescribed to prevent Wernicke-Korsakoff syndrome
in a client with chronic alcohol use disorder?
A. Lorazepam
B. Naloxone
C. Disulfiram
,D. Thiamine (Vitamin B1)
Answer: D
Rationale: Thiamine is essential for glucose metabolism in the brain, and chronic alcohol
use often leads to severe deficiency due to malabsorption. Wernicke-Korsakoff syndrome
involves serious neurological complications, including ataxia and ocular abnormalities.
Early supplementation is critical to prevent permanent cognitive impairment and
neurological damage.
3. A client diagnosed with anorexia nervosa is admitted to the unit. Which physical
assessment finding should the nurse anticipate?
A. Tachycardia and hypertension
B. Hyperthermia and moist skin
C. Hyperkalemia and metabolic acidosis
D. Lanugo and bradycardia
Answer: D
Rationale: Lanugo, which is fine, downy hair, is the body’s attempt to provide insulation in
the absence of subcutaneous fat. Bradycardia and hypotension occur as the body slows its
metabolic rate to conserve energy. These physiological changes are indicative of severe
malnutrition and require close medical monitoring.
, 4. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse respond?
A. Agree with the client’s assessment of other staff members to build rapport
B. Allow the client to choose which nurse provides care each shift
C. Maintain consistent boundaries and communicate clearly with the multidisciplinary
team
D. Ignore the behavior to avoid reinforcing the client’s manipulation
Answer: C
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad. Consistency among staff is vital to prevent the client from playing team members
against each other. Frequent team meetings and adherence to the care plan are necessary
to maintain a therapeutic environment.
5. A child with ADHD is prescribed methylphenidate. Which side effect should the nurse
instruct the parents to monitor?
A. Weight loss and insomnia
B. Excessive sleepiness during the day
C. Increased appetite and weight gain
D. Bradycardia and hypotension
Answer: A
