NUR253 Exam 4 V3 | Mental Health
Nursing Q&A with Rationale | Galen
College of Nursing
1. A client is diagnosed with delirium. Which clinical characteristic should the nurse expect to
find during the assessment?
A. Sudden onset of confusion and altered level of consciousness
B. Slow, progressive decline in cognitive function
C. Persistent, unchanging symptoms over several months
D. Intact orientation to time and place despite memory loss
Answer: A
Rationale: Delirium is characterized by a rapid onset of symptoms including fluctuating
levels of consciousness and acute confusion. Unlike dementia, which is chronic and
progressive, delirium is often reversible once the underlying cause is treated. The nurse
must prioritize identifying the physiological trigger to ensure patient safety and recovery.
2. A nurse is caring for a client with Antisocial Personality Disorder. Which behavior is most
characteristic of this diagnosis?
A. Excessive emotionality and attention-seeking behavior
B. Lack of remorse for actions and disregard for the rights of others
C. Extreme fear of abandonment and unstable relationships
,D. Social inhibition and feelings of inadequacy
Answer: B
Rationale: Antisocial Personality Disorder is defined by a pattern of disregard for and
violation of the rights of others. Individuals often exhibit a lack of empathy and do not feel
guilt or remorse for their harmful actions. Nursing interventions should focus on setting
clear boundaries and consistent consequences for manipulative behavior.
3. Which medication is the gold standard for treating symptoms of alcohol withdrawal and
preventing seizures?
A. Disulfiram
B. Lorazepam
C. Methadone
D. Naltrexone
Answer: B
Rationale: Benzodiazepines like Lorazepam are the primary treatment for alcohol
withdrawal because they provide cross-tolerance to alcohol. They help stabilize vital signs
and significantly reduce the risk of withdrawal seizures and delirium tremens. Other
medications like Disulfiram are used for maintenance of sobriety rather than acute
withdrawal management.
, 4. A client with Anorexia Nervosa is admitted to the inpatient unit. Which assessment finding
requires immediate nursing intervention?
A. Body mass index (BMI) of 17.5
B. Potassium level of 2.8 mEq/L
C. Presence of fine, downy hair (lanugo) on the back
D. Amenorrhea for the past four months
Answer: B
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which can lead to
life-threatening cardiac arrhythmias. While lanugo and low BMI are typical signs of
anorexia, electrolyte imbalances present the most immediate risk to life. The nurse must
monitor the client’s cardiac status and prepare for electrolyte replacement therapy.
5. Which personality disorder is characterized by a pervasive pattern of grandiosity, a need
for admiration, and a lack of empathy?
A. Narcissistic Personality Disorder
B. Borderline Personality Disorder
C. Histrionic Personality Disorder
D. Avoidant Personality Disorder
Answer: A
Nursing Q&A with Rationale | Galen
College of Nursing
1. A client is diagnosed with delirium. Which clinical characteristic should the nurse expect to
find during the assessment?
A. Sudden onset of confusion and altered level of consciousness
B. Slow, progressive decline in cognitive function
C. Persistent, unchanging symptoms over several months
D. Intact orientation to time and place despite memory loss
Answer: A
Rationale: Delirium is characterized by a rapid onset of symptoms including fluctuating
levels of consciousness and acute confusion. Unlike dementia, which is chronic and
progressive, delirium is often reversible once the underlying cause is treated. The nurse
must prioritize identifying the physiological trigger to ensure patient safety and recovery.
2. A nurse is caring for a client with Antisocial Personality Disorder. Which behavior is most
characteristic of this diagnosis?
A. Excessive emotionality and attention-seeking behavior
B. Lack of remorse for actions and disregard for the rights of others
C. Extreme fear of abandonment and unstable relationships
,D. Social inhibition and feelings of inadequacy
Answer: B
Rationale: Antisocial Personality Disorder is defined by a pattern of disregard for and
violation of the rights of others. Individuals often exhibit a lack of empathy and do not feel
guilt or remorse for their harmful actions. Nursing interventions should focus on setting
clear boundaries and consistent consequences for manipulative behavior.
3. Which medication is the gold standard for treating symptoms of alcohol withdrawal and
preventing seizures?
A. Disulfiram
B. Lorazepam
C. Methadone
D. Naltrexone
Answer: B
Rationale: Benzodiazepines like Lorazepam are the primary treatment for alcohol
withdrawal because they provide cross-tolerance to alcohol. They help stabilize vital signs
and significantly reduce the risk of withdrawal seizures and delirium tremens. Other
medications like Disulfiram are used for maintenance of sobriety rather than acute
withdrawal management.
, 4. A client with Anorexia Nervosa is admitted to the inpatient unit. Which assessment finding
requires immediate nursing intervention?
A. Body mass index (BMI) of 17.5
B. Potassium level of 2.8 mEq/L
C. Presence of fine, downy hair (lanugo) on the back
D. Amenorrhea for the past four months
Answer: B
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which can lead to
life-threatening cardiac arrhythmias. While lanugo and low BMI are typical signs of
anorexia, electrolyte imbalances present the most immediate risk to life. The nurse must
monitor the client’s cardiac status and prepare for electrolyte replacement therapy.
5. Which personality disorder is characterized by a pervasive pattern of grandiosity, a need
for admiration, and a lack of empathy?
A. Narcissistic Personality Disorder
B. Borderline Personality Disorder
C. Histrionic Personality Disorder
D. Avoidant Personality Disorder
Answer: A
