NUR 2459 Exam 3 Actual Exam V2 | NUR 2459 Mental and Behavioral
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A client is admitted to the hospital with a diagnosis of delirium. Which of the following
characteristics should the nurse expect to assess?
A. Slow, progressive decline in cognitive function.
B. Sudden onset of confusion with fluctuating levels of consciousness.
C. Consistent impairment in long-term memory.
D. Intact attention span despite disorientation to person.
Answer: B
Rationale: Delirium is characterized by a rapid, acute onset of symptoms rather than a
slow decline. The client typically displays a fluctuating level of consciousness throughout
the day. It is often reversible once the underlying medical cause is identified and treated.
2. A nurse is caring for a client experiencing alcohol withdrawal. Which medication is
considered the first-line treatment to manage tremors and prevent seizures?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Lorazepam
Answer: D
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help stabilize vital signs, reduce the risk of seizures,
and decrease the intensity of withdrawal tremors. Disulfiram is used for maintenance of
sobriety rather than acute withdrawal management.
3. A client with anorexia nervosa is being admitted to an inpatient unit. Which assessment
finding should the nurse prioritize as the highest risk?
A. Body mass index (BMI) of 17.5.
B. Amenorrhea for the past six months.
C. Lanugo on the back and extremities.
D. Bradycardia with a heart rate of 38 beats per minute.
Answer: D
,Rationale: Severe bradycardia indicates significant cardiac instability, which can lead to
sudden death in clients with anorexia. While low BMI and lanugo are characteristic of the
disorder, they are not immediate life threats. Physiological stability, particularly
cardiovascular status, must take precedence over behavioral symptoms.
4. The nurse is assessing a client with Borderline Personality Disorder who is ‘splitting’ the
staff by praising the night shift while criticizing the day shift. How should the nurse proceed?
A. Discuss the client’s comments with the night shift to see why they are better.
B. Explain to the client that all staff members are highly competent.
C. Limit the client’s contact with the night shift to prevent favoritism.
D. Hold a staff meeting to ensure a consistent, united approach to the client’s care.
Answer: D
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad. The nursing priority is to maintain consistency and boundaries among the
healthcare team to prevent manipulation. Staff communication is essential to ensure that
the treatment plan is followed uniformly by everyone.
5. A nurse is providing education to a client prescribed Disulfiram (Antabuse) for alcohol use
disorder. Which statement by the client indicates a need for further teaching?
A. ‘I will check labels on cough syrup for alcohol content.’
B. ‘I can safely use alcohol-based hand sanitizer while on this medication.’
C. ‘I should wait at least 12 hours after my last drink before starting this.’
D. ‘I need to avoid vinegar and vanilla extract in my food.’
Answer: B
Rationale: Disulfiram causes a severe physical reaction when even small amounts of
alcohol are absorbed through the skin or inhaled. Clients must be warned that alcohol-
based hand sanitizers, colognes, and certain toiletries can trigger a reaction. Education
must emphasize the extreme sensitivity to alcohol in all forms, including hidden sources in
food and medicine.
6. A client in the middle stages of Alzheimer’s disease consistently makes up stories to fill in
memory gaps. The nurse identifies this as which of the following?
A. Confabulation
B. Aphasia
C. Apraxia
D. Agnosia
, Answer: A
Rationale: Confabulation is a compensatory mechanism where the client creates
imaginary events to fill in memory gaps. This is not an intentional lie but rather an
unconscious attempt to maintain self-esteem. It is commonly seen in dementia and
Korsakoff’s syndrome as cognitive deficit increases.
7. A nurse is assessing an older adult client for potential elder abuse. Which finding should
raise the highest suspicion of physical neglect?
A. The client’s clothing is soiled and they have a strong odor of urine.
B. The client has several small bruises on the shins.
C. The client refuses to make eye contact during the interview.
D. The client is hesitant to talk about their financial situation.
Answer: A
Rationale: Signs of neglect include poor hygiene, soiled clothing, untreated pressure
ulcers, and malnutrition. While bruises can indicate abuse, they are common in the elderly
due to thinning skin and falls. Neglect specifically refers to the failure of a caregiver to
provide basic necessities for the client’s well-being.
8. A client with Antisocial Personality Disorder is being treated in a residential facility. Which
nursing intervention is most appropriate?
A. Encourage the client to lead group therapy sessions.
B. Provide a flexible schedule to allow for client autonomy.
C. Offer frequent praise to build the client’s low self-esteem.
D. Set clear, firm limits on behavior and consequences.
Answer: D
Rationale: Clients with Antisocial Personality Disorder often exhibit manipulative,
aggressive, and non-compliant behaviors. Effective management requires the nurse to set
firm limits and maintain clear boundaries to prevent the exploitation of others. Consistency
among all staff members is vital when enforcing these rules.
9. A nurse is caring for a client with Bulimia Nervosa. Which physical assessment finding is
most associated with this disorder?
A. Parotid gland swelling
B. Excessive body hair growth
C. Extreme cold intolerance
D. Compulsive exercising at night
Health Nursing (NUR2459 Exam 3) | Rasmussen
1. A client is admitted to the hospital with a diagnosis of delirium. Which of the following
characteristics should the nurse expect to assess?
A. Slow, progressive decline in cognitive function.
B. Sudden onset of confusion with fluctuating levels of consciousness.
C. Consistent impairment in long-term memory.
D. Intact attention span despite disorientation to person.
Answer: B
Rationale: Delirium is characterized by a rapid, acute onset of symptoms rather than a
slow decline. The client typically displays a fluctuating level of consciousness throughout
the day. It is often reversible once the underlying medical cause is identified and treated.
2. A nurse is caring for a client experiencing alcohol withdrawal. Which medication is
considered the first-line treatment to manage tremors and prevent seizures?
A. Disulfiram
B. Naltrexone
C. Methadone
D. Lorazepam
Answer: D
Rationale: Benzodiazepines like lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms. They help stabilize vital signs, reduce the risk of seizures,
and decrease the intensity of withdrawal tremors. Disulfiram is used for maintenance of
sobriety rather than acute withdrawal management.
3. A client with anorexia nervosa is being admitted to an inpatient unit. Which assessment
finding should the nurse prioritize as the highest risk?
A. Body mass index (BMI) of 17.5.
B. Amenorrhea for the past six months.
C. Lanugo on the back and extremities.
D. Bradycardia with a heart rate of 38 beats per minute.
Answer: D
,Rationale: Severe bradycardia indicates significant cardiac instability, which can lead to
sudden death in clients with anorexia. While low BMI and lanugo are characteristic of the
disorder, they are not immediate life threats. Physiological stability, particularly
cardiovascular status, must take precedence over behavioral symptoms.
4. The nurse is assessing a client with Borderline Personality Disorder who is ‘splitting’ the
staff by praising the night shift while criticizing the day shift. How should the nurse proceed?
A. Discuss the client’s comments with the night shift to see why they are better.
B. Explain to the client that all staff members are highly competent.
C. Limit the client’s contact with the night shift to prevent favoritism.
D. Hold a staff meeting to ensure a consistent, united approach to the client’s care.
Answer: D
Rationale: Splitting is a defense mechanism where the client views individuals as all good
or all bad. The nursing priority is to maintain consistency and boundaries among the
healthcare team to prevent manipulation. Staff communication is essential to ensure that
the treatment plan is followed uniformly by everyone.
5. A nurse is providing education to a client prescribed Disulfiram (Antabuse) for alcohol use
disorder. Which statement by the client indicates a need for further teaching?
A. ‘I will check labels on cough syrup for alcohol content.’
B. ‘I can safely use alcohol-based hand sanitizer while on this medication.’
C. ‘I should wait at least 12 hours after my last drink before starting this.’
D. ‘I need to avoid vinegar and vanilla extract in my food.’
Answer: B
Rationale: Disulfiram causes a severe physical reaction when even small amounts of
alcohol are absorbed through the skin or inhaled. Clients must be warned that alcohol-
based hand sanitizers, colognes, and certain toiletries can trigger a reaction. Education
must emphasize the extreme sensitivity to alcohol in all forms, including hidden sources in
food and medicine.
6. A client in the middle stages of Alzheimer’s disease consistently makes up stories to fill in
memory gaps. The nurse identifies this as which of the following?
A. Confabulation
B. Aphasia
C. Apraxia
D. Agnosia
, Answer: A
Rationale: Confabulation is a compensatory mechanism where the client creates
imaginary events to fill in memory gaps. This is not an intentional lie but rather an
unconscious attempt to maintain self-esteem. It is commonly seen in dementia and
Korsakoff’s syndrome as cognitive deficit increases.
7. A nurse is assessing an older adult client for potential elder abuse. Which finding should
raise the highest suspicion of physical neglect?
A. The client’s clothing is soiled and they have a strong odor of urine.
B. The client has several small bruises on the shins.
C. The client refuses to make eye contact during the interview.
D. The client is hesitant to talk about their financial situation.
Answer: A
Rationale: Signs of neglect include poor hygiene, soiled clothing, untreated pressure
ulcers, and malnutrition. While bruises can indicate abuse, they are common in the elderly
due to thinning skin and falls. Neglect specifically refers to the failure of a caregiver to
provide basic necessities for the client’s well-being.
8. A client with Antisocial Personality Disorder is being treated in a residential facility. Which
nursing intervention is most appropriate?
A. Encourage the client to lead group therapy sessions.
B. Provide a flexible schedule to allow for client autonomy.
C. Offer frequent praise to build the client’s low self-esteem.
D. Set clear, firm limits on behavior and consequences.
Answer: D
Rationale: Clients with Antisocial Personality Disorder often exhibit manipulative,
aggressive, and non-compliant behaviors. Effective management requires the nurse to set
firm limits and maintain clear boundaries to prevent the exploitation of others. Consistency
among all staff members is vital when enforcing these rules.
9. A nurse is caring for a client with Bulimia Nervosa. Which physical assessment finding is
most associated with this disorder?
A. Parotid gland swelling
B. Excessive body hair growth
C. Extreme cold intolerance
D. Compulsive exercising at night
