NUR 256 Exam 3 V2 | NUR 256 Concepts
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations.
Which action should the nurse take first?
A. Instruct the client to use headphones to block the sound.
B. Inform the client that the voices are not real.
C. Administer a PRN dose of haloperidol.
D. Ask the client directly what the voices are saying.
Answer: D
Rationale: The nurse’s first priority is to assess for command hallucinations that may urge
the client to harm themselves or others. Safety is the paramount concern when managing a
client with active psychosis. Asking what the voices are saying allows the nurse to
implement appropriate safety precautions immediately.
2. A client diagnosed with Borderline Personality Disorder frequently uses the defense
mechanism of splitting. How should the nursing staff respond?
A. Hold a staff meeting to discuss consistent limit setting.
B. Assign a different nurse to the client each shift.
,C. Allow the client to choose their favorite nurse for all care.
D. Ignore the behavior to avoid reinforcing it.
Answer: A
Rationale: Splitting involves the client seeing staff as ‘all good’ or ‘all bad,’ which can cause
conflict among the healthcare team. Consistency is crucial in managing these clients to
prevent manipulation and ensure a stable environment. Regular staff meetings help
maintain a unified approach to care and limit setting.
3. Which medication is considered the gold standard for treating alcohol withdrawal
symptoms and preventing seizures?
A. Disulfiram
B. Lorazepam
C. Methadone
D. Fluoxetine
Answer: B
Rationale: Benzodiazepines like lorazepam are used to stabilize vital signs and prevent the
progression of withdrawal to seizures or delirium tremens. These medications act on GABA
receptors to provide a cross-tolerance effect with alcohol. Other medications like
disulfiram are used for maintenance of sobriety rather than acute withdrawal
management.
, 4. A client with Anorexia Nervosa is being admitted to an inpatient unit. Which assessment
finding is a priority for the nurse?
A. Body weight 15% below ideal.
B. Potassium level of 2.8 mEq/L.
C. Presence of fine, downy hair (lanugo).
D. Client’s report of distorted body image.
Answer: B
Rationale: A potassium level of 2.8 mEq/L is critically low and poses an immediate risk for
life-threatening cardiac arrhythmias. Electrolyte imbalances are common in eating
disorders due to purging or malnutrition and must be addressed first. While low weight
and lanugo are diagnostic features, they do not present the same acute physiological threat
as hypokalemia.
5. A nurse is caring for a client with Alzheimer’s disease who is experiencing agnosia. Which
behavior by the client supports this diagnosis?
A. The client attempts to brush their hair with a fork.
B. The client is unable to find the correct words to speak.
C. The client is unable to perform familiar motor tasks.
D. The client cannot remember what they ate for breakfast.
Answer: A
of Mental Health Nursing | Q&A with
Rationale (NUR256 Exam 3) | Galen
College of Nursing
1. A nurse is assessing a client with schizophrenia who is experiencing auditory hallucinations.
Which action should the nurse take first?
A. Instruct the client to use headphones to block the sound.
B. Inform the client that the voices are not real.
C. Administer a PRN dose of haloperidol.
D. Ask the client directly what the voices are saying.
Answer: D
Rationale: The nurse’s first priority is to assess for command hallucinations that may urge
the client to harm themselves or others. Safety is the paramount concern when managing a
client with active psychosis. Asking what the voices are saying allows the nurse to
implement appropriate safety precautions immediately.
2. A client diagnosed with Borderline Personality Disorder frequently uses the defense
mechanism of splitting. How should the nursing staff respond?
A. Hold a staff meeting to discuss consistent limit setting.
B. Assign a different nurse to the client each shift.
,C. Allow the client to choose their favorite nurse for all care.
D. Ignore the behavior to avoid reinforcing it.
Answer: A
Rationale: Splitting involves the client seeing staff as ‘all good’ or ‘all bad,’ which can cause
conflict among the healthcare team. Consistency is crucial in managing these clients to
prevent manipulation and ensure a stable environment. Regular staff meetings help
maintain a unified approach to care and limit setting.
3. Which medication is considered the gold standard for treating alcohol withdrawal
symptoms and preventing seizures?
A. Disulfiram
B. Lorazepam
C. Methadone
D. Fluoxetine
Answer: B
Rationale: Benzodiazepines like lorazepam are used to stabilize vital signs and prevent the
progression of withdrawal to seizures or delirium tremens. These medications act on GABA
receptors to provide a cross-tolerance effect with alcohol. Other medications like
disulfiram are used for maintenance of sobriety rather than acute withdrawal
management.
, 4. A client with Anorexia Nervosa is being admitted to an inpatient unit. Which assessment
finding is a priority for the nurse?
A. Body weight 15% below ideal.
B. Potassium level of 2.8 mEq/L.
C. Presence of fine, downy hair (lanugo).
D. Client’s report of distorted body image.
Answer: B
Rationale: A potassium level of 2.8 mEq/L is critically low and poses an immediate risk for
life-threatening cardiac arrhythmias. Electrolyte imbalances are common in eating
disorders due to purging or malnutrition and must be addressed first. While low weight
and lanugo are diagnostic features, they do not present the same acute physiological threat
as hypokalemia.
5. A nurse is caring for a client with Alzheimer’s disease who is experiencing agnosia. Which
behavior by the client supports this diagnosis?
A. The client attempts to brush their hair with a fork.
B. The client is unable to find the correct words to speak.
C. The client is unable to perform familiar motor tasks.
D. The client cannot remember what they ate for breakfast.
Answer: A
