NUR 256 Exam 4 V1 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client with Alzheimer’s disease who is unable to recognize familiar
objects such as a hairbrush. How should the nurse document this finding?
A. Aphasia
B. Agnosia
C. Apraxia
D. Amnesia
Answer: B
Rationale: Agnosia is the inability to interpret sensory information and recognize objects
or people despite intact sensory function. This is a common cognitive deficit seen in
progressing neurocognitive disorders like Alzheimer’s. Proper documentation helps the
interdisciplinary team understand the specific functional limitations of the patient.
2. A client with Borderline Personality Disorder frequently tells the day shift nurse that the
night shift nurse is incompetent and mean. This behavior is known as:
A. Idealization
B. Projective identification
,C. Splitting
D. Rationalization
Answer: C
Rationale: Splitting is a defense mechanism commonly used by individuals with
Borderline Personality Disorder where they view people as all good or all bad. This
behavior often leads to conflict among staff members and is an attempt to manage intense
emotions. Consistent communication among the nursing team is essential to minimize the
effectiveness of this behavior.
3. Which assessment finding is the most critical for a nurse to monitor in a client diagnosed
with Anorexia Nervosa?
A. Amenorrhea
B. Lanugo on the back
C. Serum potassium of 2.8 mEq/L
D. Weight 15% below ideal body weight
Answer: C
Rationale: A serum potassium of 2.8 mEq/L is significantly low and poses a high risk for
life-threatening cardiac arrhythmias. Electrolyte imbalances are the primary medical
concern during the acute phase of eating disorder treatment. While the other symptoms
are characteristic of anorexia, they are not immediately life-threatening compared to
severe hypokalemia.
, 4. A nurse is caring for a client experiencing alcohol withdrawal. Which medication should the
nurse expect to administer to prevent seizures and delirium tremens?
A. Disulfiram
B. Methadone
C. Naltrexone
D. Lorazepam
Answer: D
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They work by enhancing the effect of GABA to calm the
central nervous system and prevent seizures. Disulfiram is used for maintenance of
sobriety, not for acute withdrawal symptoms.
5. A client with Antisocial Personality Disorder is being treated in an inpatient unit. Which
nursing intervention is most appropriate?
A. Encourage the client to discuss childhood trauma
B. Set clear, consistent limits on manipulative behavior
C. Provide a flexible schedule with few rules
D. Assign the same nurse for every shift
Answer: B
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 4) | Galen
College of Nursing
1. A nurse is assessing a client with Alzheimer’s disease who is unable to recognize familiar
objects such as a hairbrush. How should the nurse document this finding?
A. Aphasia
B. Agnosia
C. Apraxia
D. Amnesia
Answer: B
Rationale: Agnosia is the inability to interpret sensory information and recognize objects
or people despite intact sensory function. This is a common cognitive deficit seen in
progressing neurocognitive disorders like Alzheimer’s. Proper documentation helps the
interdisciplinary team understand the specific functional limitations of the patient.
2. A client with Borderline Personality Disorder frequently tells the day shift nurse that the
night shift nurse is incompetent and mean. This behavior is known as:
A. Idealization
B. Projective identification
,C. Splitting
D. Rationalization
Answer: C
Rationale: Splitting is a defense mechanism commonly used by individuals with
Borderline Personality Disorder where they view people as all good or all bad. This
behavior often leads to conflict among staff members and is an attempt to manage intense
emotions. Consistent communication among the nursing team is essential to minimize the
effectiveness of this behavior.
3. Which assessment finding is the most critical for a nurse to monitor in a client diagnosed
with Anorexia Nervosa?
A. Amenorrhea
B. Lanugo on the back
C. Serum potassium of 2.8 mEq/L
D. Weight 15% below ideal body weight
Answer: C
Rationale: A serum potassium of 2.8 mEq/L is significantly low and poses a high risk for
life-threatening cardiac arrhythmias. Electrolyte imbalances are the primary medical
concern during the acute phase of eating disorder treatment. While the other symptoms
are characteristic of anorexia, they are not immediately life-threatening compared to
severe hypokalemia.
, 4. A nurse is caring for a client experiencing alcohol withdrawal. Which medication should the
nurse expect to administer to prevent seizures and delirium tremens?
A. Disulfiram
B. Methadone
C. Naltrexone
D. Lorazepam
Answer: D
Rationale: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They work by enhancing the effect of GABA to calm the
central nervous system and prevent seizures. Disulfiram is used for maintenance of
sobriety, not for acute withdrawal symptoms.
5. A client with Antisocial Personality Disorder is being treated in an inpatient unit. Which
nursing intervention is most appropriate?
A. Encourage the client to discuss childhood trauma
B. Set clear, consistent limits on manipulative behavior
C. Provide a flexible schedule with few rules
D. Assign the same nurse for every shift
Answer: B
