NUR2459 Exam 2 Actual Exam Style V2 |
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’ to
manipulate staff members. Which nursing intervention is the most effective?
A. Hold a staff meeting to ensure a consistent approach and set firm limits.
B. Confront the client immediately and demand they stop the behavior.
C. Allow the client to choose which nurse will care for them each shift.
D. Assign the client a different nurse every day to prevent attachment.
Answer: A
Rationale: Splitting is a common defense mechanism where a client views people as all
good or all bad. The nursing priority is to ensure consistent communication among the
multidisciplinary team to prevent manipulation. Regular staff meetings and clear limit-
setting provide a stable environment for the client.
2. A client is admitted with Anorexia Nervosa. Which physical finding should the nurse
prioritize during the initial assessment?
A. Bradycardia and hypotension.
B. Dry, scaly skin and brittle nails.
C. The presence of fine hair (lanugo) on the back.
,D. The client’s expressed fear of gaining weight.
Answer: A
Rationale: Physiological stability is the priority when dealing with eating disorders.
Bradycardia and hypotension indicate severe cardiovascular compromise and electrolyte
imbalance that can be life-threatening. While lanugo and skin changes are characteristic of
anorexia, they are not immediate threats to life.
3. A client is experiencing symptoms of alcohol withdrawal including tremors, sweating, and a
heart rate of 110 bpm. Which medication should the nurse anticipate administering?
A. Disulfiram
B. Methadone
C. Lorazepam
D. Naloxone
Answer: C
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal. They help stabilize vital signs and prevent the progression to seizures
or delirium tremens. Disulfiram is used for maintenance and sobriety reinforcement, not
for acute withdrawal symptoms.
4. A nurse is assessing a client with Antisocial Personality Disorder. Which behavior should
the nurse expect to observe?
A. A pervasive pattern of disregard for the rights of others.
, B. Excessive need for admiration and lack of empathy.
C. Intense fear of abandonment and self-harming gestures.
D. Social isolation and odd, eccentric beliefs.
Answer: A
Rationale: Antisocial Personality Disorder is characterized by a pattern of violating laws
and the rights of others without remorse. These individuals often exhibit deceitfulness,
impulsivity, and irritability. Safety is a primary concern for the nurse because these clients
can be aggressive or manipulative.
5. An elderly client with Alzheimer’s disease is experiencing sundowning. What is the best
environmental intervention for the nurse to implement?
A. Provide a well-lit environment and consistent routine in the evening.
B. Keep the lights low throughout the day to promote rest.
C. Limit the client’s daytime naps to ensure they sleep at night.
D. Move the client to a room near the nursing station.
Answer: A
Rationale: Sundowning involves increased confusion and agitation as daylight fades.
Providing adequate lighting in the evening helps reduce shadows that can cause
hallucinations or delusions. Maintaining a predictable routine helps the client feel more
secure and less disoriented.
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’ to
manipulate staff members. Which nursing intervention is the most effective?
A. Hold a staff meeting to ensure a consistent approach and set firm limits.
B. Confront the client immediately and demand they stop the behavior.
C. Allow the client to choose which nurse will care for them each shift.
D. Assign the client a different nurse every day to prevent attachment.
Answer: A
Rationale: Splitting is a common defense mechanism where a client views people as all
good or all bad. The nursing priority is to ensure consistent communication among the
multidisciplinary team to prevent manipulation. Regular staff meetings and clear limit-
setting provide a stable environment for the client.
2. A client is admitted with Anorexia Nervosa. Which physical finding should the nurse
prioritize during the initial assessment?
A. Bradycardia and hypotension.
B. Dry, scaly skin and brittle nails.
C. The presence of fine hair (lanugo) on the back.
,D. The client’s expressed fear of gaining weight.
Answer: A
Rationale: Physiological stability is the priority when dealing with eating disorders.
Bradycardia and hypotension indicate severe cardiovascular compromise and electrolyte
imbalance that can be life-threatening. While lanugo and skin changes are characteristic of
anorexia, they are not immediate threats to life.
3. A client is experiencing symptoms of alcohol withdrawal including tremors, sweating, and a
heart rate of 110 bpm. Which medication should the nurse anticipate administering?
A. Disulfiram
B. Methadone
C. Lorazepam
D. Naloxone
Answer: C
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal. They help stabilize vital signs and prevent the progression to seizures
or delirium tremens. Disulfiram is used for maintenance and sobriety reinforcement, not
for acute withdrawal symptoms.
4. A nurse is assessing a client with Antisocial Personality Disorder. Which behavior should
the nurse expect to observe?
A. A pervasive pattern of disregard for the rights of others.
, B. Excessive need for admiration and lack of empathy.
C. Intense fear of abandonment and self-harming gestures.
D. Social isolation and odd, eccentric beliefs.
Answer: A
Rationale: Antisocial Personality Disorder is characterized by a pattern of violating laws
and the rights of others without remorse. These individuals often exhibit deceitfulness,
impulsivity, and irritability. Safety is a primary concern for the nurse because these clients
can be aggressive or manipulative.
5. An elderly client with Alzheimer’s disease is experiencing sundowning. What is the best
environmental intervention for the nurse to implement?
A. Provide a well-lit environment and consistent routine in the evening.
B. Keep the lights low throughout the day to promote rest.
C. Limit the client’s daytime naps to ensure they sleep at night.
D. Move the client to a room near the nursing station.
Answer: A
Rationale: Sundowning involves increased confusion and agitation as daylight fades.
Providing adequate lighting in the evening helps reduce shadows that can cause
hallucinations or delusions. Maintaining a predictable routine helps the client feel more
secure and less disoriented.
