NUR253 Exam 4 V2 | Mental Health
Nursing Q&A with Rationale | Galen
College of Nursing
1. A client with Borderline Personality Disorder tells a nurse, ‘You are the only one who truly
cares for me; the day shift nurse is incompetent.’ What defense mechanism is being
exhibited?
A. Reaction formation
B. Rationalization
C. Projection
D. Splitting
Answer: D
Rationale: Splitting is a defense mechanism common in borderline personality disorder
where individuals view people or things as all good or all bad. This behavior helps the
client manage intense emotions but creates conflict among staff members. The nursing
team must maintain consistent boundaries and communicate frequently to prevent being
manipulated by these perceptions.
2. A nurse is caring for an elderly client who is experiencing a sudden onset of confusion and
visual hallucinations. Which condition should the nurse suspect?
A. Schizophrenia
,B. Alzheimer’s disease
C. Vascular dementia
D. Delirium
Answer: D
Rationale: Delirium is characterized by an acute, rapid onset of confusion and changes in
cognition or perception. Unlike dementia, which is progressive and chronic, delirium is
often reversible if the underlying cause like infection or medication is treated. The priority
is to identify the medical cause while ensuring the client’s safety during the episode.
3. A client is admitted for alcohol detoxification. Which medication should the nurse expect
to administer to manage acute withdrawal symptoms?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Chlordiazepoxide
Answer: D
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent seizures and manage
agitation during acute alcohol withdrawal. This class of medication helps stabilize vital
signs and prevents the progression to delirium tremens. Nurses must monitor the client
closely using the CIWA scale to determine appropriate dosing.
, 4. Which physical finding is most associated with a client who has been practicing self-
induced vomiting for several years due to Bulimia Nervosa?
A. Lanugo
B. Peripheral edema
C. Russell’s sign
D. Amenorrhea
Answer: C
Rationale: Russell’s sign refers to calluses on the knuckles caused by repeated contact with
the teeth during induced vomiting. This is a common physical indicator that a client is
engaging in purging behaviors. The nurse should also monitor for dental enamel erosion
and parotid gland swelling as part of the assessment.
5. A nurse is assessing a child for possible Attention-Deficit/Hyperactivity Disorder (ADHD).
Which behavior is a hallmark of this condition?
A. Physical aggression toward animals
B. Severe social isolation and lack of eye contact
C. Persistent patterns of inattention and impulsivity
D. Intentional destruction of property
Answer: C
Nursing Q&A with Rationale | Galen
College of Nursing
1. A client with Borderline Personality Disorder tells a nurse, ‘You are the only one who truly
cares for me; the day shift nurse is incompetent.’ What defense mechanism is being
exhibited?
A. Reaction formation
B. Rationalization
C. Projection
D. Splitting
Answer: D
Rationale: Splitting is a defense mechanism common in borderline personality disorder
where individuals view people or things as all good or all bad. This behavior helps the
client manage intense emotions but creates conflict among staff members. The nursing
team must maintain consistent boundaries and communicate frequently to prevent being
manipulated by these perceptions.
2. A nurse is caring for an elderly client who is experiencing a sudden onset of confusion and
visual hallucinations. Which condition should the nurse suspect?
A. Schizophrenia
,B. Alzheimer’s disease
C. Vascular dementia
D. Delirium
Answer: D
Rationale: Delirium is characterized by an acute, rapid onset of confusion and changes in
cognition or perception. Unlike dementia, which is progressive and chronic, delirium is
often reversible if the underlying cause like infection or medication is treated. The priority
is to identify the medical cause while ensuring the client’s safety during the episode.
3. A client is admitted for alcohol detoxification. Which medication should the nurse expect
to administer to manage acute withdrawal symptoms?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Chlordiazepoxide
Answer: D
Rationale: Chlordiazepoxide is a benzodiazepine used to prevent seizures and manage
agitation during acute alcohol withdrawal. This class of medication helps stabilize vital
signs and prevents the progression to delirium tremens. Nurses must monitor the client
closely using the CIWA scale to determine appropriate dosing.
, 4. Which physical finding is most associated with a client who has been practicing self-
induced vomiting for several years due to Bulimia Nervosa?
A. Lanugo
B. Peripheral edema
C. Russell’s sign
D. Amenorrhea
Answer: C
Rationale: Russell’s sign refers to calluses on the knuckles caused by repeated contact with
the teeth during induced vomiting. This is a common physical indicator that a client is
engaging in purging behaviors. The nurse should also monitor for dental enamel erosion
and parotid gland swelling as part of the assessment.
5. A nurse is assessing a child for possible Attention-Deficit/Hyperactivity Disorder (ADHD).
Which behavior is a hallmark of this condition?
A. Physical aggression toward animals
B. Severe social isolation and lack of eye contact
C. Persistent patterns of inattention and impulsivity
D. Intentional destruction of property
Answer: C
