NUR253 Exam 3 V1 | NUR 253 Mental
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client experiencing alcohol withdrawal. Which medication should the
nurse anticipate administering to prevent seizures and delirium tremens?
A. Methadone
B. Naloxone
C. Disulfiram
D. Chlordiazepoxide
Answer: D
Rationale: Chlordiazepoxide is a benzodiazepine used to stabilize vital signs and prevent
seizures during acute alcohol withdrawal. It works by enhancing the effects of GABA in the
central nervous system to provide sedation. The nurse must monitor the client closely for
respiratory depression and over-sedation during administration.
2. A client with Borderline Personality Disorder frequently pits staff members against each
other. What is the best nursing intervention for this behavior?
A. Allow the client to choose which nurse will provide care.
B. Hold a staff meeting to discuss the client’s behavior and ensure consistent limits.
C. Ignore the behavior to avoid reinforcing it.
,D. Transfer the client to a different unit immediately.
Answer: B
Rationale: The client is utilizing a defense mechanism known as ‘splitting,’ which involves
viewing people as either all good or all bad. Consistency among the treatment team is vital
to prevent the client from manipulating staff and to provide a stable environment. Regular
communication helps ensure that all staff members are adhering to the same plan of care
and limit-setting.
3. Which assessment finding is a priority for a client suspected of an opioid overdose?
A. Pinpoint pupils and respiratory rate of 8 breaths/min
B. Tachycardia and hypertension
C. Hyperactive bowel sounds
D. Visual hallucinations and tremors
Answer: A
Rationale: Opioid toxicity typically presents with a triad of symptoms: coma, pinpoint
pupils, and respiratory depression. A respiratory rate of 8 is dangerously low and requires
immediate intervention with an opioid antagonist like Naloxone. Ensuring the airway is
patent and maintaining ventilation is the primary nursing priority in this life-threatening
situation.
, 4. A client is admitted after a sudden house fire destroyed all of their belongings. What type
of crisis is this client experiencing?
A. Maturational crisis
B. Situational crisis
C. Developmental crisis
D. Adventitious crisis
Answer: D
Rationale: An adventitious crisis is a rare, unplanned event that is catastrophic or violent
in nature, such as a natural disaster or a house fire. This differs from situational crises,
which are often related to common life events like job loss or divorce. The nurse should
focus on immediate safety and basic needs for a client experiencing this level of trauma.
5. A client with Antisocial Personality Disorder is being treated in an inpatient unit. Which
behavior is most characteristic of this disorder?
A. Excessive emotionality and attention-seeking
B. Social inhibition and feelings of inadequacy
C. Fear of abandonment and unstable relationships
D. Lack of remorse for hurting others and manipulation
Answer: D
Health Nursing Exam Q&A | Galen College
of Nursing
1. A nurse is caring for a client experiencing alcohol withdrawal. Which medication should the
nurse anticipate administering to prevent seizures and delirium tremens?
A. Methadone
B. Naloxone
C. Disulfiram
D. Chlordiazepoxide
Answer: D
Rationale: Chlordiazepoxide is a benzodiazepine used to stabilize vital signs and prevent
seizures during acute alcohol withdrawal. It works by enhancing the effects of GABA in the
central nervous system to provide sedation. The nurse must monitor the client closely for
respiratory depression and over-sedation during administration.
2. A client with Borderline Personality Disorder frequently pits staff members against each
other. What is the best nursing intervention for this behavior?
A. Allow the client to choose which nurse will provide care.
B. Hold a staff meeting to discuss the client’s behavior and ensure consistent limits.
C. Ignore the behavior to avoid reinforcing it.
,D. Transfer the client to a different unit immediately.
Answer: B
Rationale: The client is utilizing a defense mechanism known as ‘splitting,’ which involves
viewing people as either all good or all bad. Consistency among the treatment team is vital
to prevent the client from manipulating staff and to provide a stable environment. Regular
communication helps ensure that all staff members are adhering to the same plan of care
and limit-setting.
3. Which assessment finding is a priority for a client suspected of an opioid overdose?
A. Pinpoint pupils and respiratory rate of 8 breaths/min
B. Tachycardia and hypertension
C. Hyperactive bowel sounds
D. Visual hallucinations and tremors
Answer: A
Rationale: Opioid toxicity typically presents with a triad of symptoms: coma, pinpoint
pupils, and respiratory depression. A respiratory rate of 8 is dangerously low and requires
immediate intervention with an opioid antagonist like Naloxone. Ensuring the airway is
patent and maintaining ventilation is the primary nursing priority in this life-threatening
situation.
, 4. A client is admitted after a sudden house fire destroyed all of their belongings. What type
of crisis is this client experiencing?
A. Maturational crisis
B. Situational crisis
C. Developmental crisis
D. Adventitious crisis
Answer: D
Rationale: An adventitious crisis is a rare, unplanned event that is catastrophic or violent
in nature, such as a natural disaster or a house fire. This differs from situational crises,
which are often related to common life events like job loss or divorce. The nurse should
focus on immediate safety and basic needs for a client experiencing this level of trauma.
5. A client with Antisocial Personality Disorder is being treated in an inpatient unit. Which
behavior is most characteristic of this disorder?
A. Excessive emotionality and attention-seeking
B. Social inhibition and feelings of inadequacy
C. Fear of abandonment and unstable relationships
D. Lack of remorse for hurting others and manipulation
Answer: D
