NUR 2459 Exam 4 Actual Exam V1 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who states,
‘You are the only nurse who actually cares about me; all the others are mean.’ How should
the nurse interpret this behavior?
A. The client is using a defense mechanism called splitting
B. The client is demonstrating healthy rapport building
C. The client is experiencing a manic episode
D. The client is exhibiting altruistic behavior
Answer: A
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as entirely good or entirely bad. This behavior often leads to
conflict within the healthcare team as the client attempts to play staff against each other.
The nurse should recognize this and maintain consistent boundaries and communication
with the rest of the treatment team.
2. A client with Anorexia Nervosa is admitted to the inpatient unit. Which of the following
physical assessment findings should the nurse prioritize as a clinical emergency?
A. Heart rate of 38 beats per minute
B. Presence of lanugo on the back
C. Amenorrhea for six months
D. Dry, brittle hair and nails
Answer: A
Rationale: Severe bradycardia (heart rate below 40 bpm) indicates significant
cardiovascular instability and is a criterion for immediate medical hospitalization. While
lanugo and amenorrhea are common signs of anorexia, they are not immediately life-
threatening. The nurse must prioritize physiological stability, specifically cardiac function,
in patients with severe malnutrition.
3. A nurse is assessing a child with Autism Spectrum Disorder (ASD). Which characteristic
behavior should the nurse expect to observe?
A. Repetitive motor movements or speech
B. Excessive talkativeness and social engagement
C. High levels of empathy for peers
,D. Preference for spontaneous, unplanned activities
Answer: A
Rationale: Repetitive motor movements, such as hand-flapping or rocking, and
stereotyped speech are core diagnostic features of ASD. Children with ASD often struggle
with social-emotional reciprocity and have a strong preference for routine and
predictability. Understanding these behaviors helps the nurse create a therapeutic
environment that minimizes sensory overload.
4. An elderly client is brought to the emergency department with a sudden onset of
confusion, disorientation, and visual hallucinations. The symptoms fluctuate throughout the
day. Which condition is most likely?
A. Alzheimer’s Disease
B. Vascular Dementia
C. Depression
D. Delirium
Answer: D
Rationale: Delirium is characterized by an acute onset, fluctuating levels of consciousness,
and often has an underlying medical cause such as infection or medication toxicity. Unlike
dementia, which is progressive and irreversible, delirium is usually reversible once the
underlying cause is treated. The nurse’s priority is to identify and address the physiological
trigger to ensure patient safety.
5. A client with Antisocial Personality Disorder is being treated in a group setting. Which
behavior is the nurse most likely to observe?
A. Extreme shyness and avoidance of conflict
B. Excessive need for approval and reassurance
C. Lack of remorse for exploiting others
D. Meticulous attention to rules and order
Answer: C
Rationale: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others and a lack of remorse for harmful actions. These
individuals often engage in deceitful or manipulative behaviors for personal gain. The
nursing focus should be on setting firm, consistent limits and holding the client accountable
for their actions.
6. A nurse is providing education to the parents of a child newly diagnosed with ADHD who is
starting Methylphenidate. Which instruction is most important?
A. Administer the medication right before bedtime
, B. Monitor the child’s height and weight regularly
C. Expect the child to become very drowsy during the day
D. The medication will take 4-6 weeks to show any effect
Answer: B
Rationale: Stimulant medications like Methylphenidate can cause appetite suppression
and potential growth delays in children. It is essential for parents to track growth
parameters to ensure the child is developing appropriately. Additionally, the medication
should be given in the morning to avoid insomnia, as it is a central nervous system
stimulant.
7. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering to prevent Wernicke-Korsakoff syndrome?
A. Lorazepam
B. Disulfiram
C. Thiamine (Vitamin B1)
D. Naloxone
Answer: C
Rationale: Thiamine deficiency is common in chronic alcohol use and can lead to
Wernicke-Korsakoff syndrome, a serious neurological condition. Administering thiamine
helps prevent permanent brain damage and cognitive impairment. While Lorazepam is
used to manage withdrawal symptoms, thiamine specifically targets the nutritional
deficiency associated with this syndrome.
8. A nurse is caring for a client with Bulimia Nervosa. Which physical finding is most
suggestive of self-induced vomiting?
A. Lanugo
B. Parotid gland swelling
C. Hypotension
D. Hyperkalemia
Answer: B
Rationale: Parotid gland swelling, also known as ‘chipmunk cheeks,’ occurs due to the
irritation caused by repeated vomiting. Other signs include dental erosion and Russell’s
sign (calluses on the knuckles). The nurse should also monitor for hypokalemia, as
vomiting leads to significant electrolyte loss, which can be life-threatening.
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who states,
‘You are the only nurse who actually cares about me; all the others are mean.’ How should
the nurse interpret this behavior?
A. The client is using a defense mechanism called splitting
B. The client is demonstrating healthy rapport building
C. The client is experiencing a manic episode
D. The client is exhibiting altruistic behavior
Answer: A
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as entirely good or entirely bad. This behavior often leads to
conflict within the healthcare team as the client attempts to play staff against each other.
The nurse should recognize this and maintain consistent boundaries and communication
with the rest of the treatment team.
2. A client with Anorexia Nervosa is admitted to the inpatient unit. Which of the following
physical assessment findings should the nurse prioritize as a clinical emergency?
A. Heart rate of 38 beats per minute
B. Presence of lanugo on the back
C. Amenorrhea for six months
D. Dry, brittle hair and nails
Answer: A
Rationale: Severe bradycardia (heart rate below 40 bpm) indicates significant
cardiovascular instability and is a criterion for immediate medical hospitalization. While
lanugo and amenorrhea are common signs of anorexia, they are not immediately life-
threatening. The nurse must prioritize physiological stability, specifically cardiac function,
in patients with severe malnutrition.
3. A nurse is assessing a child with Autism Spectrum Disorder (ASD). Which characteristic
behavior should the nurse expect to observe?
A. Repetitive motor movements or speech
B. Excessive talkativeness and social engagement
C. High levels of empathy for peers
,D. Preference for spontaneous, unplanned activities
Answer: A
Rationale: Repetitive motor movements, such as hand-flapping or rocking, and
stereotyped speech are core diagnostic features of ASD. Children with ASD often struggle
with social-emotional reciprocity and have a strong preference for routine and
predictability. Understanding these behaviors helps the nurse create a therapeutic
environment that minimizes sensory overload.
4. An elderly client is brought to the emergency department with a sudden onset of
confusion, disorientation, and visual hallucinations. The symptoms fluctuate throughout the
day. Which condition is most likely?
A. Alzheimer’s Disease
B. Vascular Dementia
C. Depression
D. Delirium
Answer: D
Rationale: Delirium is characterized by an acute onset, fluctuating levels of consciousness,
and often has an underlying medical cause such as infection or medication toxicity. Unlike
dementia, which is progressive and irreversible, delirium is usually reversible once the
underlying cause is treated. The nurse’s priority is to identify and address the physiological
trigger to ensure patient safety.
5. A client with Antisocial Personality Disorder is being treated in a group setting. Which
behavior is the nurse most likely to observe?
A. Extreme shyness and avoidance of conflict
B. Excessive need for approval and reassurance
C. Lack of remorse for exploiting others
D. Meticulous attention to rules and order
Answer: C
Rationale: Antisocial Personality Disorder is characterized by a pervasive pattern of
disregard for the rights of others and a lack of remorse for harmful actions. These
individuals often engage in deceitful or manipulative behaviors for personal gain. The
nursing focus should be on setting firm, consistent limits and holding the client accountable
for their actions.
6. A nurse is providing education to the parents of a child newly diagnosed with ADHD who is
starting Methylphenidate. Which instruction is most important?
A. Administer the medication right before bedtime
, B. Monitor the child’s height and weight regularly
C. Expect the child to become very drowsy during the day
D. The medication will take 4-6 weeks to show any effect
Answer: B
Rationale: Stimulant medications like Methylphenidate can cause appetite suppression
and potential growth delays in children. It is essential for parents to track growth
parameters to ensure the child is developing appropriately. Additionally, the medication
should be given in the morning to avoid insomnia, as it is a central nervous system
stimulant.
7. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering to prevent Wernicke-Korsakoff syndrome?
A. Lorazepam
B. Disulfiram
C. Thiamine (Vitamin B1)
D. Naloxone
Answer: C
Rationale: Thiamine deficiency is common in chronic alcohol use and can lead to
Wernicke-Korsakoff syndrome, a serious neurological condition. Administering thiamine
helps prevent permanent brain damage and cognitive impairment. While Lorazepam is
used to manage withdrawal symptoms, thiamine specifically targets the nutritional
deficiency associated with this syndrome.
8. A nurse is caring for a client with Bulimia Nervosa. Which physical finding is most
suggestive of self-induced vomiting?
A. Lanugo
B. Parotid gland swelling
C. Hypotension
D. Hyperkalemia
Answer: B
Rationale: Parotid gland swelling, also known as ‘chipmunk cheeks,’ occurs due to the
irritation caused by repeated vomiting. Other signs include dental erosion and Russell’s
sign (calluses on the knuckles). The nurse should also monitor for hypokalemia, as
vomiting leads to significant electrolyte loss, which can be life-threatening.
