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 with Borderline Personality Disorder who alternates between
praising and devaluing staff members. What is the most appropriate nursing intervention for
this behavior?
A. Assign the client to a different nurse each shift to prevent attachment.
B. Allow the client to choose their favorite nurse to decrease anxiety.
C. Confront the client about their manipulative behavior immediately.
D. Hold a staff meeting to ensure a consistent approach and set firm boundaries.
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as entirely good or entirely bad. Maintaining consistency
among the nursing team is crucial to prevent the patient from playing staff members
against one another. A unified approach ensures that boundaries are clear and limits are
enforced uniformly across all shifts.
2. A client with Anorexia Nervosa has a body mass index (BMI) of 15 and is admitted to the
unit. Which assessment finding should the nurse prioritize as the most immediate concern?
A. Distorted body image and fear of weight gain.
B. Lanugo on the back and extremities.
C. Amenorrhea for the past six months.
D. Heart rate of 38 beats per minute and hypotension.
Answer: D
Rationale: Physiological stability is the first priority in patients with severe malnutrition
from Anorexia Nervosa. Extreme bradycardia and hypotension indicate cardiac instability
and a high risk for sudden cardiac arrest. While psychological symptoms and lanugo are
characteristic of the disorder, they do not pose an immediate threat to life like
hemodynamic instability does.
3. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse anticipate administering first?
A. Lorazepam (Ativan)
B. Naltrexone (ReVia)
C. Disulfiram (Antabuse)
,D. Fluoxetine (Prozac)
Answer: A
Rationale: Benzodiazepines such as Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. These medications cross-react with alcohol at the GABA
receptors to prevent seizures and delirium tremens. Other medications like Disulfiram are
used for long-term maintenance rather than acute withdrawal management.
4. A nurse is conducting a crisis intervention for a client who just lost their home in a fire.
Which action should the nurse take first?
A. Refer the client to a long-term grief counseling support group.
B. Assess the client’s immediate safety and basic needs for food and shelter.
C. Explore the client’s childhood coping mechanisms for trauma.
D. Encourage the client to express their feelings about the loss.
Answer: B
Rationale: In the initial phase of crisis intervention, Maslow’s Hierarchy of Needs dictates
that physical safety and physiological requirements come first. The nurse must ensure the
client is not suicidal and has a safe place to stay before addressing psychological
processing. Focused, directive communication is most effective during the acute phase of a
crisis.
5. A client with Antisocial Personality Disorder is demanding a cigarette even though it is
outside of the scheduled break time. How should the nurse respond?
A. Give the client a cigarette this once to avoid a confrontation.
B. Tell the client, ‘You can have a cigarette if you attend the next group session.’
C. State, ‘Cigarette breaks only occur at the scheduled times of 10:00 and 2:00.’
D. Ignore the request and walk away to show that the behavior is unacceptable.
Answer: C
Rationale: Patients with Antisocial Personality Disorder often try to manipulate rules and
push boundaries. Using firm, matter-of-fact communication to restate the rules prevents
power struggles and reinforces the milieu’s structure. Bargaining or giving in reinforces the
patient’s manipulative behaviors and undermines the treatment plan.
6. A nurse is caring for a client with Somatic Symptom Disorder who continues to focus on
vague physical pains. Which nursing intervention is most appropriate?
A. Explain to the client that their medical tests are all normal and the pain is psychological.
B. Acknowledge the client’s complaint but gently redirect the conversation to their feelings.
, C. Provide extra attention whenever the client mentions a new physical symptom.
D. Advise the client to seek a second opinion from a different specialist.
Answer: B
Rationale: Clients with Somatic Symptom Disorder experience real distress despite a lack
of physical evidence for their symptoms. The nurse should validate the client’s experience
without focusing extensively on the physical complaint, as this helps shift the focus to
underlying emotional issues. Direct confrontation about the psychological nature of the
pain often causes the client to feel dismissed and defensive.
7. A client with Obsessive-Compulsive Disorder (OCD) is late for breakfast because they must
wash their hands 10 times before leaving the room. What is the nurse’s best response?
A. Stop the client after the second wash and lead them to the dining hall.
B. Allow the client to finish the ritual but plan to start the morning routine earlier
tomorrow.
C. Explain that handwashing is unnecessary because they are in a clean hospital.
D. Request a prescription for a higher dose of an antipsychotic medication.
Answer: B
Rationale: In the early stages of treatment for OCD, stopping rituals abruptly can cause
overwhelming anxiety and panic. The nurse should allow the ritual to occur initially while
modifying the schedule to accommodate the time needed. Over time, the treatment team
will work with the client to gradually reduce the frequency and duration of these
behaviors.
8. Which assessment finding is characteristic of a client suffering from Bulimia Nervosa?
A. Severe emaciation and refusal to maintain a normal body weight.
B. Complete lack of interest in food or caloric intake.
C. Calluses on the knuckles (Russell’s sign) and dental erosion.
D. High levels of self-esteem and confidence regarding body image.
Answer: C
Rationale: Russell’s sign refers to calluses on the hand used to induce vomiting, a hallmark
sign of the purging type of Bulimia. Dental erosion occurs due to repeated exposure of the
teeth to acidic gastric contents during vomiting. Unlike Anorexia, clients with Bulimia often
maintain a weight that is near or slightly above normal.
9. A client is prescribed Disulfiram (Antabuse) for alcohol use disorder. Which information is
most critical for the nurse to include in the teaching plan?
A. The medication should be taken only when you feel an urge to drink.
Health Nursing (NUR2459 Exam 4) | Rasmussen
1. A nurse is caring for a client with Borderline Personality Disorder who alternates between
praising and devaluing staff members. What is the most appropriate nursing intervention for
this behavior?
A. Assign the client to a different nurse each shift to prevent attachment.
B. Allow the client to choose their favorite nurse to decrease anxiety.
C. Confront the client about their manipulative behavior immediately.
D. Hold a staff meeting to ensure a consistent approach and set firm boundaries.
Answer: D
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where individuals view others as entirely good or entirely bad. Maintaining consistency
among the nursing team is crucial to prevent the patient from playing staff members
against one another. A unified approach ensures that boundaries are clear and limits are
enforced uniformly across all shifts.
2. A client with Anorexia Nervosa has a body mass index (BMI) of 15 and is admitted to the
unit. Which assessment finding should the nurse prioritize as the most immediate concern?
A. Distorted body image and fear of weight gain.
B. Lanugo on the back and extremities.
C. Amenorrhea for the past six months.
D. Heart rate of 38 beats per minute and hypotension.
Answer: D
Rationale: Physiological stability is the first priority in patients with severe malnutrition
from Anorexia Nervosa. Extreme bradycardia and hypotension indicate cardiac instability
and a high risk for sudden cardiac arrest. While psychological symptoms and lanugo are
characteristic of the disorder, they do not pose an immediate threat to life like
hemodynamic instability does.
3. A client is experiencing alcohol withdrawal and exhibits tremors, diaphoresis, and a heart
rate of 110 bpm. Which medication should the nurse anticipate administering first?
A. Lorazepam (Ativan)
B. Naltrexone (ReVia)
C. Disulfiram (Antabuse)
,D. Fluoxetine (Prozac)
Answer: A
Rationale: Benzodiazepines such as Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. These medications cross-react with alcohol at the GABA
receptors to prevent seizures and delirium tremens. Other medications like Disulfiram are
used for long-term maintenance rather than acute withdrawal management.
4. A nurse is conducting a crisis intervention for a client who just lost their home in a fire.
Which action should the nurse take first?
A. Refer the client to a long-term grief counseling support group.
B. Assess the client’s immediate safety and basic needs for food and shelter.
C. Explore the client’s childhood coping mechanisms for trauma.
D. Encourage the client to express their feelings about the loss.
Answer: B
Rationale: In the initial phase of crisis intervention, Maslow’s Hierarchy of Needs dictates
that physical safety and physiological requirements come first. The nurse must ensure the
client is not suicidal and has a safe place to stay before addressing psychological
processing. Focused, directive communication is most effective during the acute phase of a
crisis.
5. A client with Antisocial Personality Disorder is demanding a cigarette even though it is
outside of the scheduled break time. How should the nurse respond?
A. Give the client a cigarette this once to avoid a confrontation.
B. Tell the client, ‘You can have a cigarette if you attend the next group session.’
C. State, ‘Cigarette breaks only occur at the scheduled times of 10:00 and 2:00.’
D. Ignore the request and walk away to show that the behavior is unacceptable.
Answer: C
Rationale: Patients with Antisocial Personality Disorder often try to manipulate rules and
push boundaries. Using firm, matter-of-fact communication to restate the rules prevents
power struggles and reinforces the milieu’s structure. Bargaining or giving in reinforces the
patient’s manipulative behaviors and undermines the treatment plan.
6. A nurse is caring for a client with Somatic Symptom Disorder who continues to focus on
vague physical pains. Which nursing intervention is most appropriate?
A. Explain to the client that their medical tests are all normal and the pain is psychological.
B. Acknowledge the client’s complaint but gently redirect the conversation to their feelings.
, C. Provide extra attention whenever the client mentions a new physical symptom.
D. Advise the client to seek a second opinion from a different specialist.
Answer: B
Rationale: Clients with Somatic Symptom Disorder experience real distress despite a lack
of physical evidence for their symptoms. The nurse should validate the client’s experience
without focusing extensively on the physical complaint, as this helps shift the focus to
underlying emotional issues. Direct confrontation about the psychological nature of the
pain often causes the client to feel dismissed and defensive.
7. A client with Obsessive-Compulsive Disorder (OCD) is late for breakfast because they must
wash their hands 10 times before leaving the room. What is the nurse’s best response?
A. Stop the client after the second wash and lead them to the dining hall.
B. Allow the client to finish the ritual but plan to start the morning routine earlier
tomorrow.
C. Explain that handwashing is unnecessary because they are in a clean hospital.
D. Request a prescription for a higher dose of an antipsychotic medication.
Answer: B
Rationale: In the early stages of treatment for OCD, stopping rituals abruptly can cause
overwhelming anxiety and panic. The nurse should allow the ritual to occur initially while
modifying the schedule to accommodate the time needed. Over time, the treatment team
will work with the client to gradually reduce the frequency and duration of these
behaviors.
8. Which assessment finding is characteristic of a client suffering from Bulimia Nervosa?
A. Severe emaciation and refusal to maintain a normal body weight.
B. Complete lack of interest in food or caloric intake.
C. Calluses on the knuckles (Russell’s sign) and dental erosion.
D. High levels of self-esteem and confidence regarding body image.
Answer: C
Rationale: Russell’s sign refers to calluses on the hand used to induce vomiting, a hallmark
sign of the purging type of Bulimia. Dental erosion occurs due to repeated exposure of the
teeth to acidic gastric contents during vomiting. Unlike Anorexia, clients with Bulimia often
maintain a weight that is near or slightly above normal.
9. A client is prescribed Disulfiram (Antabuse) for alcohol use disorder. Which information is
most critical for the nurse to include in the teaching plan?
A. The medication should be taken only when you feel an urge to drink.
