NSRG 126 Exam 3 V2 | NSRG 126 Mental
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 3) | Ivy Tech
1. A nurse is caring for an older adult client who is experiencing a sudden onset of confusion
and visual hallucinations. Which characteristic best distinguishes this condition from
dementia?
A. Progressive memory loss
B. Rapid onset of symptoms with fluctuating levels of consciousness
C. Stable symptoms throughout the day
D. Irreversible neurological damage
Correct Answer: B
Delirium is characterized by an acute onset and a fluctuating course of symptoms. Unlike
dementia, which is chronic and progressive, delirium is often secondary to an underlying
medical condition such as infection or dehydration. The nurse must prioritize identifying
and treating the physiological cause to resolve the cognitive impairment.
2. A nurse in a substance use disorder clinic is assessing a client for alcohol withdrawal. Which
of the following findings should the nurse expect?
A. Bradycardia and hypotension
B. Pinpoint pupils and respiratory depression
,C. Fine tremors of both hands and tachycardia
D. Increased appetite and hypersomnia
E. Muscle flaccidity and euphoria
Correct Answer: C
Alcohol withdrawal typically begins 6 to 8 hours after the last drink and manifests as
autonomic hyperactivity. Signs include tremors, tachycardia, elevated blood pressure, and
anxiety. It is critical for the nurse to monitor these symptoms using the CIWA scale to
prevent progression to delirium tremens.
3. A client with Anorexia Nervosa is being admitted to the inpatient unit. Which of the
following clinical findings would meet the criteria for hospitalization?
A. Body weight 15% below ideal
B. History of purging twice weekly
C. Serum potassium level of 3.8 mEq/L
D. Heart rate less than 40 beats per minute
Correct Answer: D
Severe physiological instability is the primary indication for acute hospitalization in eating
disorders. A heart rate below 40 bpm or a systolic blood pressure below 70 mmHg
indicates significant cardiovascular risk. The nurse must focus on stabilization of vital signs
and electrolyte balance before intensive psychotherapy can be effective.
,4. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse respond to this behavior?
A. Argue with the client about their perception of staff
B. Provide extra attention to the client to build trust
C. Allow the client to choose which nurse they work with
D. Hold a staff meeting to ensure consistency and set firm boundaries
Correct Answer: D
Splitting is a defense mechanism where the client views individuals as all good or all bad.
This behavior often creates conflict among the treatment team and disrupts the therapeutic
environment. Maintaining consistent boundaries and clear communication among staff is
essential to prevent the client’s attempts to manipulate the care plan.
5. Which medication is considered the first-line treatment for a client experiencing acute
alcohol withdrawal symptoms?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Chlordiazepoxide
Correct Answer: D
, Benzodiazepines like chlordiazepoxide or lorazepam are the gold standard for managing
acute alcohol withdrawal. They help prevent seizures and delirium tremens by providing
cross-tolerance to alcohol. The dosage is typically titrated based on the severity of
symptoms recorded on the CIWA-Ar scale.
6. A nurse is assessing risk factors for a client who has expressed suicidal ideation. Which of
the following factors significantly increase the risk of a completed suicide attempt?
A. The client is female
B. The client has strong religious affiliations
C. The client has young children at home
D. The client has a history of a previous suicide attempt
E. The client is currently employed
F. The client lives in a community with limited access to firearms
Correct Answer: D
A history of prior attempts is one of the strongest predictors of future completed suicide.
Other high-risk factors include being male, living alone, and having a specific, lethal plan
with access to means. Assessment of these factors allows the nurse to determine the
necessary level of observation and safety precautions.
7. A client is diagnosed with Antisocial Personality Disorder. Which of the following behaviors
is the nurse most likely to observe?
A. Extreme social anxiety and fear of rejection
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 3) | Ivy Tech
1. A nurse is caring for an older adult client who is experiencing a sudden onset of confusion
and visual hallucinations. Which characteristic best distinguishes this condition from
dementia?
A. Progressive memory loss
B. Rapid onset of symptoms with fluctuating levels of consciousness
C. Stable symptoms throughout the day
D. Irreversible neurological damage
Correct Answer: B
Delirium is characterized by an acute onset and a fluctuating course of symptoms. Unlike
dementia, which is chronic and progressive, delirium is often secondary to an underlying
medical condition such as infection or dehydration. The nurse must prioritize identifying
and treating the physiological cause to resolve the cognitive impairment.
2. A nurse in a substance use disorder clinic is assessing a client for alcohol withdrawal. Which
of the following findings should the nurse expect?
A. Bradycardia and hypotension
B. Pinpoint pupils and respiratory depression
,C. Fine tremors of both hands and tachycardia
D. Increased appetite and hypersomnia
E. Muscle flaccidity and euphoria
Correct Answer: C
Alcohol withdrawal typically begins 6 to 8 hours after the last drink and manifests as
autonomic hyperactivity. Signs include tremors, tachycardia, elevated blood pressure, and
anxiety. It is critical for the nurse to monitor these symptoms using the CIWA scale to
prevent progression to delirium tremens.
3. A client with Anorexia Nervosa is being admitted to the inpatient unit. Which of the
following clinical findings would meet the criteria for hospitalization?
A. Body weight 15% below ideal
B. History of purging twice weekly
C. Serum potassium level of 3.8 mEq/L
D. Heart rate less than 40 beats per minute
Correct Answer: D
Severe physiological instability is the primary indication for acute hospitalization in eating
disorders. A heart rate below 40 bpm or a systolic blood pressure below 70 mmHg
indicates significant cardiovascular risk. The nurse must focus on stabilization of vital signs
and electrolyte balance before intensive psychotherapy can be effective.
,4. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
behavior. How should the nurse respond to this behavior?
A. Argue with the client about their perception of staff
B. Provide extra attention to the client to build trust
C. Allow the client to choose which nurse they work with
D. Hold a staff meeting to ensure consistency and set firm boundaries
Correct Answer: D
Splitting is a defense mechanism where the client views individuals as all good or all bad.
This behavior often creates conflict among the treatment team and disrupts the therapeutic
environment. Maintaining consistent boundaries and clear communication among staff is
essential to prevent the client’s attempts to manipulate the care plan.
5. Which medication is considered the first-line treatment for a client experiencing acute
alcohol withdrawal symptoms?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Chlordiazepoxide
Correct Answer: D
, Benzodiazepines like chlordiazepoxide or lorazepam are the gold standard for managing
acute alcohol withdrawal. They help prevent seizures and delirium tremens by providing
cross-tolerance to alcohol. The dosage is typically titrated based on the severity of
symptoms recorded on the CIWA-Ar scale.
6. A nurse is assessing risk factors for a client who has expressed suicidal ideation. Which of
the following factors significantly increase the risk of a completed suicide attempt?
A. The client is female
B. The client has strong religious affiliations
C. The client has young children at home
D. The client has a history of a previous suicide attempt
E. The client is currently employed
F. The client lives in a community with limited access to firearms
Correct Answer: D
A history of prior attempts is one of the strongest predictors of future completed suicide.
Other high-risk factors include being male, living alone, and having a specific, lethal plan
with access to means. Assessment of these factors allows the nurse to determine the
necessary level of observation and safety precautions.
7. A client is diagnosed with Antisocial Personality Disorder. Which of the following behaviors
is the nurse most likely to observe?
A. Extreme social anxiety and fear of rejection
