NSRG 126 Exam 4 V1 | NSRG 126 Mental
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 4) | Ivy Tech
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ as a defense mechanism. Which nursing intervention is most appropriate?
A. Encourage the client to discuss their feelings with multiple staff members to get different
perspectives.
B. Allow the client to choose which nurse they prefer to work with during the shift.
C. Hold a staff meeting to ensure a consistent approach and consistent limit-setting by all
team members.
D. Ignore the behavior as it is a common symptom of the disorder and will resolve on its
own.
Correct Answer: C
Splitting involves the inability to integrate positive and negative qualities of oneself or
others into a cohesive image. By maintaining a consistent team approach, the staff prevents
the client from playing one staff member against another. This consistency is vital in
providing a stable environment and therapeutic boundaries for the client.
,2. A client is admitted to the inpatient unit with a diagnosis of Anorexia Nervosa. Which of
the following clinical manifestations should the nurse expect to find during the initial
assessment?
A. Tachycardia and hypertension
B. Bradycardia, hypotension, and the presence of lanugo.
C. Hyperkalemia and metabolic acidosis
D. Heavy menstrual cycles and increased body temperature
E. Peripheral edema and oily skin
Correct Answer: B
Anorexia Nervosa often leads to physiological adaptations to starvation, such as a slowed
heart rate and lowered blood pressure. Lanugo, or fine downy hair, grows as the body
attempts to insulate itself due to the loss of subcutaneous fat. Amenorrhea, rather than
heavy cycles, is also a classic finding in these clients.
3. A nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
would indicate that the client is experiencing alcohol withdrawal delirium (delirium
tremens)?
A. Visual hallucinations, severe hypertension, and diaphoresis.
B. Bradycardia and hypotension
C. Apathy and somnolence
, D. Increased appetite and hypersomnia
Correct Answer: A
Alcohol withdrawal delirium is a medical emergency that typically occurs 48 to 72 hours
after the last drink. It is characterized by severe autonomic hyperactivity, including
tachycardia, sweating, and high blood pressure. Sensory alterations such as vivid visual or
tactile hallucinations are hallmarks of this condition.
4. Which medication should the nurse anticipate administering to a client experiencing an
acute opioid overdose?
A. Methadone
B. Buprenorphine
C. Naloxone
D. Disulfiram
Correct Answer: C
Naloxone is an opioid antagonist that quickly reverses the effects of opioids on the central
nervous system. It is specifically used in emergency situations to treat respiratory
depression caused by overdose. Methadone and Buprenorphine are used for maintenance
or withdrawal management, not acute reversal.
5. A client with Antisocial Personality Disorder is being treated on a psychiatric unit. Which
behavior is most characteristic of this disorder?
A. Extreme social isolation and fear of rejection
Health Nursing | Actual Q&A with
Rationale (NSRG126 Exam 4) | Ivy Tech
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ as a defense mechanism. Which nursing intervention is most appropriate?
A. Encourage the client to discuss their feelings with multiple staff members to get different
perspectives.
B. Allow the client to choose which nurse they prefer to work with during the shift.
C. Hold a staff meeting to ensure a consistent approach and consistent limit-setting by all
team members.
D. Ignore the behavior as it is a common symptom of the disorder and will resolve on its
own.
Correct Answer: C
Splitting involves the inability to integrate positive and negative qualities of oneself or
others into a cohesive image. By maintaining a consistent team approach, the staff prevents
the client from playing one staff member against another. This consistency is vital in
providing a stable environment and therapeutic boundaries for the client.
,2. A client is admitted to the inpatient unit with a diagnosis of Anorexia Nervosa. Which of
the following clinical manifestations should the nurse expect to find during the initial
assessment?
A. Tachycardia and hypertension
B. Bradycardia, hypotension, and the presence of lanugo.
C. Hyperkalemia and metabolic acidosis
D. Heavy menstrual cycles and increased body temperature
E. Peripheral edema and oily skin
Correct Answer: B
Anorexia Nervosa often leads to physiological adaptations to starvation, such as a slowed
heart rate and lowered blood pressure. Lanugo, or fine downy hair, grows as the body
attempts to insulate itself due to the loss of subcutaneous fat. Amenorrhea, rather than
heavy cycles, is also a classic finding in these clients.
3. A nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
would indicate that the client is experiencing alcohol withdrawal delirium (delirium
tremens)?
A. Visual hallucinations, severe hypertension, and diaphoresis.
B. Bradycardia and hypotension
C. Apathy and somnolence
, D. Increased appetite and hypersomnia
Correct Answer: A
Alcohol withdrawal delirium is a medical emergency that typically occurs 48 to 72 hours
after the last drink. It is characterized by severe autonomic hyperactivity, including
tachycardia, sweating, and high blood pressure. Sensory alterations such as vivid visual or
tactile hallucinations are hallmarks of this condition.
4. Which medication should the nurse anticipate administering to a client experiencing an
acute opioid overdose?
A. Methadone
B. Buprenorphine
C. Naloxone
D. Disulfiram
Correct Answer: C
Naloxone is an opioid antagonist that quickly reverses the effects of opioids on the central
nervous system. It is specifically used in emergency situations to treat respiratory
depression caused by overdose. Methadone and Buprenorphine are used for maintenance
or withdrawal management, not acute reversal.
5. A client with Antisocial Personality Disorder is being treated on a psychiatric unit. Which
behavior is most characteristic of this disorder?
A. Extreme social isolation and fear of rejection
