NSG 322/NSG322 Exam 3 V2 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A patient with Generalized Anxiety Disorder (GAD) is prescribed Buspirone (Buspar). Which
statement by the patient indicates a need for further education?
A. I will take this medication every day as scheduled.
B. It may take 2 to 4 weeks for this drug to be fully effective.
C. I can take this medication when I feel a panic attack coming on.
D. I should avoid drinking grapefruit juice while on this medicine.
Answer: C
Rationale: Buspirone is not an ‘as needed’ (PRN) medication because it does not have
immediate effects like benzodiazepines. It requires daily administration for several weeks
to reach therapeutic levels in the bloodstream. The patient must understand that it is used
for chronic management rather than acute symptom relief.
2. A nurse is caring for a client with Anorexia Nervosa who is beginning a refeeding protocol.
Which laboratory value is the priority to monitor to prevent Refeeding Syndrome?
A. Serum Phosphorus
B. Serum Sodium
C. Blood Urea Nitrogen
,D. Hemoglobin
Answer: A
Rationale: Hypophosphatemia is the hallmark of refeeding syndrome and can lead to
cardiac arrhythmias or respiratory failure. When a malnourished patient begins eating, the
shift from catabolism to anabolism causes minerals to move into the cells rapidly. Frequent
monitoring of electrolytes is essential during the first week of nutritional restoration.
3. A patient diagnosed with Obsessive-Compulsive Disorder (OCD) spends 45 minutes
washing their hands after touching a doorknob. What is the nurse’s best initial action?
A. Immediately prevent the patient from washing their hands.
B. Allow the patient to finish the ritual initially while setting future limits.
C. Explain that the doorknob is clean and the germs are gone.
D. Assign a task for the patient to complete during their ritual time.
Answer: B
Rationale: Initially, stopping a ritual can cause an overwhelming spike in anxiety for the
OCD patient. The nurse should allow time for the ritual in the beginning of treatment while
establishing a therapeutic relationship. Over time, the nurse and patient will work together
to set limits and use exposure and response prevention (ERP) techniques.
4. Which clinical manifestation is most characteristic of Post-Traumatic Stress Disorder (PTSD)
in a combat veteran?
A. Excessive cleaning and organization rituals.
, B. Rapid speech and decreased need for sleep.
C. Hypervigilance and exaggerated startle response.
D. Multiple physical complaints with no medical cause.
Answer: C
Rationale: Hypervigilance is a core symptom of PTSD, reflecting the patient’s constant
state of high alert. This is often accompanied by flashbacks, nightmares, and avoidance of
triggers associated with the trauma. Assessing the severity of these symptoms is crucial for
determining the level of psychiatric intervention required.
5. A client is admitted for Alcohol Withdrawal. The nurse observes tremors, tachycardia, and
diaphoresis. Which medication should the nurse expect to administer first?
A. Disulfiram (Antabuse)
B. Methadone
C. Lorazepam (Ativan)
D. Fluoxetine (Prozac)
Answer: C
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They prevent the progression to seizures and delirium
tremens by providing cross-tolerance to alcohol. This treatment is typically guided by the
Clinical Institute Withdrawal Assessment (CIWA) scale.
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A patient with Generalized Anxiety Disorder (GAD) is prescribed Buspirone (Buspar). Which
statement by the patient indicates a need for further education?
A. I will take this medication every day as scheduled.
B. It may take 2 to 4 weeks for this drug to be fully effective.
C. I can take this medication when I feel a panic attack coming on.
D. I should avoid drinking grapefruit juice while on this medicine.
Answer: C
Rationale: Buspirone is not an ‘as needed’ (PRN) medication because it does not have
immediate effects like benzodiazepines. It requires daily administration for several weeks
to reach therapeutic levels in the bloodstream. The patient must understand that it is used
for chronic management rather than acute symptom relief.
2. A nurse is caring for a client with Anorexia Nervosa who is beginning a refeeding protocol.
Which laboratory value is the priority to monitor to prevent Refeeding Syndrome?
A. Serum Phosphorus
B. Serum Sodium
C. Blood Urea Nitrogen
,D. Hemoglobin
Answer: A
Rationale: Hypophosphatemia is the hallmark of refeeding syndrome and can lead to
cardiac arrhythmias or respiratory failure. When a malnourished patient begins eating, the
shift from catabolism to anabolism causes minerals to move into the cells rapidly. Frequent
monitoring of electrolytes is essential during the first week of nutritional restoration.
3. A patient diagnosed with Obsessive-Compulsive Disorder (OCD) spends 45 minutes
washing their hands after touching a doorknob. What is the nurse’s best initial action?
A. Immediately prevent the patient from washing their hands.
B. Allow the patient to finish the ritual initially while setting future limits.
C. Explain that the doorknob is clean and the germs are gone.
D. Assign a task for the patient to complete during their ritual time.
Answer: B
Rationale: Initially, stopping a ritual can cause an overwhelming spike in anxiety for the
OCD patient. The nurse should allow time for the ritual in the beginning of treatment while
establishing a therapeutic relationship. Over time, the nurse and patient will work together
to set limits and use exposure and response prevention (ERP) techniques.
4. Which clinical manifestation is most characteristic of Post-Traumatic Stress Disorder (PTSD)
in a combat veteran?
A. Excessive cleaning and organization rituals.
, B. Rapid speech and decreased need for sleep.
C. Hypervigilance and exaggerated startle response.
D. Multiple physical complaints with no medical cause.
Answer: C
Rationale: Hypervigilance is a core symptom of PTSD, reflecting the patient’s constant
state of high alert. This is often accompanied by flashbacks, nightmares, and avoidance of
triggers associated with the trauma. Assessing the severity of these symptoms is crucial for
determining the level of psychiatric intervention required.
5. A client is admitted for Alcohol Withdrawal. The nurse observes tremors, tachycardia, and
diaphoresis. Which medication should the nurse expect to administer first?
A. Disulfiram (Antabuse)
B. Methadone
C. Lorazepam (Ativan)
D. Fluoxetine (Prozac)
Answer: C
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They prevent the progression to seizures and delirium
tremens by providing cross-tolerance to alcohol. This treatment is typically guided by the
Clinical Institute Withdrawal Assessment (CIWA) scale.
