NUR 208/NUR208 Exam 4 V2 | Mental Health
Nursing Q&A with Rationale | Fortis College
1. A client with Borderline Personality Disorder (BPD) tells a morning nurse that she is the
‘only one who understands’ and that the evening nurse is ‘mean and incompetent.’ Which
defense mechanism is the nurse observing?
A. Reaction formation
B. Projection
C. Splitting
D. Sublimation
Correct Answer: C
Explanation: Splitting is a common defense mechanism in BPD where patients view
individuals as all good or all bad. This behavior often leads to conflict and manipulation
within the healthcare team. The nurse must recognize this to maintain consistent
boundaries and a united treatment approach.
2. A nurse is caring for a client with Anorexia Nervosa who is beginning a refeeding protocol.
Which laboratory value should the nurse monitor most closely to prevent life-threatening
complications?
A. Serum Sodium
B. Serum Potassium
,C. Serum Creatinine
D. Serum Phosphate
Correct Answer: D
Explanation: Refeeding syndrome is characterized by severe electrolyte shifts, particularly
hypophosphatemia, as the body moves from a catabolic to an anabolic state. Low
phosphate levels can lead to cardiac arrhythmias, respiratory failure, and seizures.
Frequent monitoring of serum phosphorus, magnesium, and potassium is essential during
the initial stages of nutritional rehabilitation.
3. An older adult client is admitted with sudden onset confusion, visual hallucinations, and
agitation. The nurse notes the client has a urinary tract infection (UTI). What is the likely
diagnosis?
A. Alzheimer’s Disease
B. Vascular Dementia
C. Delirium
D. Schizophrenia
Correct Answer: C
Explanation: Delirium is an acute, reversible state of confusion that is often caused by an
underlying medical condition such as an infection. Unlike dementia, delirium has a rapid
onset and fluctuations in consciousness and attention. Treating the underlying UTI is the
priority to resolve the cognitive symptoms.
, 4. Which clinical manifestation is most characteristic of a client diagnosed with Antisocial
Personality Disorder?
A. Extreme shyness and social withdrawal
B. Excessive need to be taken care of by others
C. Obsessive attention to detail and rules
D. Lack of remorse for violating the rights of others
Correct Answer: D
Explanation: Antisocial Personality Disorder is defined by a pervasive pattern of disregard
for and violation of the rights of others. Individuals often exhibit deceitfulness, impulsivity,
and a profound lack of guilt or remorse for their actions. This lack of empathy distinguishes
it from other personality disorders and presents significant challenges in therapeutic
settings.
5. A nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
would indicate the client is experiencing delirium tremens (DTs)?
A. Bradycardia and hypotension
B. Hypertension, diaphoresis, and hallucinations
C. Mild tremors and insomnia
D. Pinpoint pupils and respiratory depression
Correct Answer: B
Nursing Q&A with Rationale | Fortis College
1. A client with Borderline Personality Disorder (BPD) tells a morning nurse that she is the
‘only one who understands’ and that the evening nurse is ‘mean and incompetent.’ Which
defense mechanism is the nurse observing?
A. Reaction formation
B. Projection
C. Splitting
D. Sublimation
Correct Answer: C
Explanation: Splitting is a common defense mechanism in BPD where patients view
individuals as all good or all bad. This behavior often leads to conflict and manipulation
within the healthcare team. The nurse must recognize this to maintain consistent
boundaries and a united treatment approach.
2. A nurse is caring for a client with Anorexia Nervosa who is beginning a refeeding protocol.
Which laboratory value should the nurse monitor most closely to prevent life-threatening
complications?
A. Serum Sodium
B. Serum Potassium
,C. Serum Creatinine
D. Serum Phosphate
Correct Answer: D
Explanation: Refeeding syndrome is characterized by severe electrolyte shifts, particularly
hypophosphatemia, as the body moves from a catabolic to an anabolic state. Low
phosphate levels can lead to cardiac arrhythmias, respiratory failure, and seizures.
Frequent monitoring of serum phosphorus, magnesium, and potassium is essential during
the initial stages of nutritional rehabilitation.
3. An older adult client is admitted with sudden onset confusion, visual hallucinations, and
agitation. The nurse notes the client has a urinary tract infection (UTI). What is the likely
diagnosis?
A. Alzheimer’s Disease
B. Vascular Dementia
C. Delirium
D. Schizophrenia
Correct Answer: C
Explanation: Delirium is an acute, reversible state of confusion that is often caused by an
underlying medical condition such as an infection. Unlike dementia, delirium has a rapid
onset and fluctuations in consciousness and attention. Treating the underlying UTI is the
priority to resolve the cognitive symptoms.
, 4. Which clinical manifestation is most characteristic of a client diagnosed with Antisocial
Personality Disorder?
A. Extreme shyness and social withdrawal
B. Excessive need to be taken care of by others
C. Obsessive attention to detail and rules
D. Lack of remorse for violating the rights of others
Correct Answer: D
Explanation: Antisocial Personality Disorder is defined by a pervasive pattern of disregard
for and violation of the rights of others. Individuals often exhibit deceitfulness, impulsivity,
and a profound lack of guilt or remorse for their actions. This lack of empathy distinguishes
it from other personality disorders and presents significant challenges in therapeutic
settings.
5. A nurse is assessing a client for alcohol withdrawal. Which of the following symptoms
would indicate the client is experiencing delirium tremens (DTs)?
A. Bradycardia and hypotension
B. Hypertension, diaphoresis, and hallucinations
C. Mild tremors and insomnia
D. Pinpoint pupils and respiratory depression
Correct Answer: B
