NUR2459/NUR 2459 Exam 4 V2 | Mental
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A client with Borderline Personality Disorder is being admitted to the unit. The nurse
understands that this client is most likely to use which defense mechanism?
A. Sublimation
B. Splitting
C. Reaction Formation
D. Intellectualization
Answer: B
Rationale: Splitting is a hallmark defense mechanism in Borderline Personality Disorder
where the client views people or situations as either all good or all bad. This behavior often
leads to conflict among staff members as the client tries to pit them against each other.
Nurses must maintain consistent boundaries and communicate frequently to prevent this
manipulation.
2. Which assessment finding is a priority for a nurse caring for a client with Anorexia
Nervosa?
A. Potassium level of 2.8 mEq/L
B. Presence of lanugo on the back
,C. Preoccupation with food recipes
D. Amenorrhea for three months
Answer: A
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which poses a
life-threatening risk of cardiac arrhythmias. While lanugo and amenorrhea are common
findings in anorexia, they are not immediate physiological emergencies. The nurse must
prioritize electrolyte stabilization to prevent cardiac arrest in these patients.
3. A nurse is teaching the parents of a child with ADHD about Methylphenidate. What
instruction should the nurse include?
A. Administer the medication right before bedtime.
B. Expect an increase in appetite during the first month.
C. Monitor the child’s height and weight regularly.
D. Avoid protein-rich foods while taking this drug.
Answer: C
Rationale: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation in children. It is essential for parents to track growth
milestones to ensure the child is developing appropriately despite the medication. Giving
the medication late in the day should be avoided as it can cause insomnia.
, 4. A client with Antisocial Personality Disorder is being manipulative toward the staff. What is
the most appropriate nursing intervention?
A. Allow the client to set their own rules for the unit.
B. Explain the rationale behind every rule in detail.
C. Provide extra attention when the client is demanding.
D. Establish clear and firm limits on behavior.
Answer: D
Rationale: Setting clear, firm, and consistent limits is crucial when dealing with individuals
who have Antisocial Personality Disorder. These clients often lack empathy and tend to
exploit others or disregard rules for personal gain. A unified staff approach prevents the
client from finding loopholes in the unit’s structure.
5. A client is experiencing symptoms of alcohol withdrawal, including tremors and
tachycardia. Which medication is the nurse likely to administer?
A. Lorazepam
B. Haloperidol
C. Lithium
D. Fluoxetine
Answer: A
and Behavioral Health Nursing Q&A with
Rationale | Rasmussen University
1. A client with Borderline Personality Disorder is being admitted to the unit. The nurse
understands that this client is most likely to use which defense mechanism?
A. Sublimation
B. Splitting
C. Reaction Formation
D. Intellectualization
Answer: B
Rationale: Splitting is a hallmark defense mechanism in Borderline Personality Disorder
where the client views people or situations as either all good or all bad. This behavior often
leads to conflict among staff members as the client tries to pit them against each other.
Nurses must maintain consistent boundaries and communicate frequently to prevent this
manipulation.
2. Which assessment finding is a priority for a nurse caring for a client with Anorexia
Nervosa?
A. Potassium level of 2.8 mEq/L
B. Presence of lanugo on the back
,C. Preoccupation with food recipes
D. Amenorrhea for three months
Answer: A
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which poses a
life-threatening risk of cardiac arrhythmias. While lanugo and amenorrhea are common
findings in anorexia, they are not immediate physiological emergencies. The nurse must
prioritize electrolyte stabilization to prevent cardiac arrest in these patients.
3. A nurse is teaching the parents of a child with ADHD about Methylphenidate. What
instruction should the nurse include?
A. Administer the medication right before bedtime.
B. Expect an increase in appetite during the first month.
C. Monitor the child’s height and weight regularly.
D. Avoid protein-rich foods while taking this drug.
Answer: C
Rationale: Methylphenidate is a stimulant that can cause side effects such as appetite
suppression and growth retardation in children. It is essential for parents to track growth
milestones to ensure the child is developing appropriately despite the medication. Giving
the medication late in the day should be avoided as it can cause insomnia.
, 4. A client with Antisocial Personality Disorder is being manipulative toward the staff. What is
the most appropriate nursing intervention?
A. Allow the client to set their own rules for the unit.
B. Explain the rationale behind every rule in detail.
C. Provide extra attention when the client is demanding.
D. Establish clear and firm limits on behavior.
Answer: D
Rationale: Setting clear, firm, and consistent limits is crucial when dealing with individuals
who have Antisocial Personality Disorder. These clients often lack empathy and tend to
exploit others or disregard rules for personal gain. A unified staff approach prevents the
client from finding loopholes in the unit’s structure.
5. A client is experiencing symptoms of alcohol withdrawal, including tremors and
tachycardia. Which medication is the nurse likely to administer?
A. Lorazepam
B. Haloperidol
C. Lithium
D. Fluoxetine
Answer: A
