NSG 3450 Exam 3 V3 | NSG 3450 Mental Health
Guide | Actual Q&A with Rationale (NSG3450 Exam
3) | Galen College of Nursing
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘The voices are telling me to hurt myself.’ Which is the priority nursing action?
A. Place the client on one-to-one suicide precautions.
B. Ask the client to describe the voices in detail.
C. Administer a PRN dose of an antipsychotic medication.
D. Reassure the client that the voices are not real.
Correct Answer: A
Explanation: Safety is the absolute priority when a client reports command hallucinations
directed at self-harm. Command hallucinations increase the risk of dangerous behavior,
necessitating immediate and close supervision to prevent injury. The nurse must
implement suicide precautions and stay with the client until their safety is ensured.
2. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality
Disorder. The nurse observes the client praising one staff member while criticizing another.
Which defense mechanism is this client demonstrating?
A. Reaction formation
B. Splitting
,C. Projection
D. Rationalization
Correct Answer: B
Explanation: Splitting is a common defense mechanism in clients with Borderline
Personality Disorder where individuals or situations are perceived as all good or all bad.
This inability to integrate the positive and negative qualities of others helps the client
manage their intense emotions and fear of abandonment. The nursing staff must remain
consistent and maintain professional boundaries to counter this behavior.
3. A patient is exhibiting signs of alcohol withdrawal, including tremors, tachycardia, and
diaphoresis. Which medication should the nurse anticipate administering first?
A. Lorazepam
B. Disulfiram
C. Methadone
D. Naltrexone
Correct Answer: A
Explanation: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms and preventing progression to seizures or delirium tremens.
These medications provide cross-tolerance with alcohol to stabilize the central nervous
system. Disulfiram and Naltrexone are used for long-term sobriety maintenance rather
than acute withdrawal management.
, 4. The nurse is caring for a client with Anorexia Nervosa who has started a refeeding program.
Which laboratory value should the nurse monitor most closely for ‘Refeeding Syndrome’?
A. Serum Phosphate
B. Serum Potassium
C. Serum Sodium
D. Blood Urea Nitrogen
Correct Answer: A
Explanation: Refeeding syndrome is a potentially fatal condition characterized by severe
electrolyte shifts, particularly hypophosphatemia, when nutrition is reintroduced too
rapidly. Phosphate levels drop as cells take up minerals to synthesize ATP after a period of
starvation. Monitoring these levels is critical to prevent cardiac failure and respiratory
distress during the recovery phase.
5. A nurse is assessing a client for Antisocial Personality Disorder. Which finding is most
characteristic of this diagnosis?
A. Excessive emotionality and attention-seeking behavior
B. Preoccupation with orderliness and perfectionism
C. Fear of rejection leading to social isolation
D. Lack of remorse for hurting others and disregard for rules
Correct Answer: D
Guide | Actual Q&A with Rationale (NSG3450 Exam
3) | Galen College of Nursing
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations and tells the
nurse, ‘The voices are telling me to hurt myself.’ Which is the priority nursing action?
A. Place the client on one-to-one suicide precautions.
B. Ask the client to describe the voices in detail.
C. Administer a PRN dose of an antipsychotic medication.
D. Reassure the client that the voices are not real.
Correct Answer: A
Explanation: Safety is the absolute priority when a client reports command hallucinations
directed at self-harm. Command hallucinations increase the risk of dangerous behavior,
necessitating immediate and close supervision to prevent injury. The nurse must
implement suicide precautions and stay with the client until their safety is ensured.
2. A client is admitted to the psychiatric unit with a diagnosis of Borderline Personality
Disorder. The nurse observes the client praising one staff member while criticizing another.
Which defense mechanism is this client demonstrating?
A. Reaction formation
B. Splitting
,C. Projection
D. Rationalization
Correct Answer: B
Explanation: Splitting is a common defense mechanism in clients with Borderline
Personality Disorder where individuals or situations are perceived as all good or all bad.
This inability to integrate the positive and negative qualities of others helps the client
manage their intense emotions and fear of abandonment. The nursing staff must remain
consistent and maintain professional boundaries to counter this behavior.
3. A patient is exhibiting signs of alcohol withdrawal, including tremors, tachycardia, and
diaphoresis. Which medication should the nurse anticipate administering first?
A. Lorazepam
B. Disulfiram
C. Methadone
D. Naltrexone
Correct Answer: A
Explanation: Benzodiazepines like Lorazepam are the gold standard for managing acute
alcohol withdrawal symptoms and preventing progression to seizures or delirium tremens.
These medications provide cross-tolerance with alcohol to stabilize the central nervous
system. Disulfiram and Naltrexone are used for long-term sobriety maintenance rather
than acute withdrawal management.
, 4. The nurse is caring for a client with Anorexia Nervosa who has started a refeeding program.
Which laboratory value should the nurse monitor most closely for ‘Refeeding Syndrome’?
A. Serum Phosphate
B. Serum Potassium
C. Serum Sodium
D. Blood Urea Nitrogen
Correct Answer: A
Explanation: Refeeding syndrome is a potentially fatal condition characterized by severe
electrolyte shifts, particularly hypophosphatemia, when nutrition is reintroduced too
rapidly. Phosphate levels drop as cells take up minerals to synthesize ATP after a period of
starvation. Monitoring these levels is critical to prevent cardiac failure and respiratory
distress during the recovery phase.
5. A nurse is assessing a client for Antisocial Personality Disorder. Which finding is most
characteristic of this diagnosis?
A. Excessive emotionality and attention-seeking behavior
B. Preoccupation with orderliness and perfectionism
C. Fear of rejection leading to social isolation
D. Lack of remorse for hurting others and disregard for rules
Correct Answer: D
