NSRG 126 Exam 4 V1 | NSRG 126 Mental Health
Nursing | Actual Q&A with Rationale (NSRG126
Exam 4) | Ivy Tech
1. A nurse is monitoring a client who is undergoing alcohol withdrawal. Which of the
following manifestations should the nurse identify as an early sign of withdrawal?
A. Bradycardia
B. Tems and tremors
C. Hypotension
D. Increased appetite
E. Hypersomnia
Correct Answer: B
Explanation: Early manifestations of alcohol withdrawal usually begin within 6 to 8 hours
after the last drink. These signs include fine tremors, tachycardia, and elevated blood
pressure. The nurse must recognize these symptoms early to initiate the prescribed
detoxification protocol and prevent seizures or delirium tremens.
2. A nurse is caring for a client who has stage 2 Alzheimer’s disease. Which of the following
findings should the nurse expect?
A. Total loss of verbal communication
B. Frequent wandering and getting lost
,C. Inability to recognize family members
D. Loss of all motor skills
Correct Answer: B
Explanation: Stage 2, or moderate Alzheimer’s disease, is characterized by increased
memory loss and confusion. Clients often experience difficulty performing complex tasks
and may begin to wander away from home. The nurse should focus on providing a safe
environment and routine to minimize agitation and injury.
3. A nurse is assessing a client with Borderline Personality Disorder. Which of the following
behaviors is a hallmark characteristic of this disorder?
A. Excessive perfectionism
B. Splitting behavior regarding staff members
C. Extreme social isolation
D. Lack of remorse for harming others
Correct Answer: B
Explanation: Splitting is a common defense mechanism in clients with Borderline
Personality Disorder where they view individuals as all good or all bad. This behavior often
creates conflict within the treatment team as the client attempts to pit staff members
against each other. Consistent communication among the healthcare team is vital to
maintain boundaries and provide effective care.
,4. A nurse is admitting a client who has Anorexia Nervosa and is at 60% of their ideal body
weight. Which of the following interventions is the priority?
A. Initiating continuous cardiac monitoring
B. Setting a target weight for discharge
C. Encouraging the client to attend group therapy
D. Discussing the client’s body image perception
Correct Answer: A
Explanation: Clients with severe anorexia nervosa are at high risk for electrolyte
imbalances and cardiac arrhythmias due to starvation. Physical stabilization is the
immediate priority over psychological interventions when life-threatening physiological
symptoms are present. The nurse must monitor for bradycardia and QT interval
prolongation to prevent sudden cardiac arrest.
5. A nurse is educating the parents of a child with Conduct Disorder. Which of the following
characteristics should the nurse include in the teaching?
A. Excessive shyness in social situations
B. Fear of being separated from primary caregivers
C. Difficulty sustaining attention in class
D. Lack of remorse for violating the rights of others
Correct Answer: D
, Explanation: Conduct disorder involves a repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate societal norms are violated.
Children with this disorder often display aggression toward people and animals and show
little empathy or guilt for their actions. It is distinct from Oppositional Defiant Disorder,
which is characterized by defiance but generally lacks the severe aggression or theft seen in
Conduct Disorder.
6. A nurse is differentiating between delirium and dementia in an older adult client. Which of
the following features is unique to delirium?
A. Slow, progressive onset of memory loss
B. Irreversible cognitive decline
C. Difficulty with word-finding
D. Flat affect and social withdrawal
E. Presence of aphasia and apraxia
F. Altered level of consciousness that fluctuates
Correct Answer: F
Explanation: Delirium is characterized by a rapid onset and a fluctuating level of
consciousness, which is not typical of dementia. While dementia is a slow, progressive
decline, delirium is often caused by an underlying medical condition like an infection or
medication toxicity. Identifying the underlying cause is essential because delirium is
generally reversible once the cause is treated.
Nursing | Actual Q&A with Rationale (NSRG126
Exam 4) | Ivy Tech
1. A nurse is monitoring a client who is undergoing alcohol withdrawal. Which of the
following manifestations should the nurse identify as an early sign of withdrawal?
A. Bradycardia
B. Tems and tremors
C. Hypotension
D. Increased appetite
E. Hypersomnia
Correct Answer: B
Explanation: Early manifestations of alcohol withdrawal usually begin within 6 to 8 hours
after the last drink. These signs include fine tremors, tachycardia, and elevated blood
pressure. The nurse must recognize these symptoms early to initiate the prescribed
detoxification protocol and prevent seizures or delirium tremens.
2. A nurse is caring for a client who has stage 2 Alzheimer’s disease. Which of the following
findings should the nurse expect?
A. Total loss of verbal communication
B. Frequent wandering and getting lost
,C. Inability to recognize family members
D. Loss of all motor skills
Correct Answer: B
Explanation: Stage 2, or moderate Alzheimer’s disease, is characterized by increased
memory loss and confusion. Clients often experience difficulty performing complex tasks
and may begin to wander away from home. The nurse should focus on providing a safe
environment and routine to minimize agitation and injury.
3. A nurse is assessing a client with Borderline Personality Disorder. Which of the following
behaviors is a hallmark characteristic of this disorder?
A. Excessive perfectionism
B. Splitting behavior regarding staff members
C. Extreme social isolation
D. Lack of remorse for harming others
Correct Answer: B
Explanation: Splitting is a common defense mechanism in clients with Borderline
Personality Disorder where they view individuals as all good or all bad. This behavior often
creates conflict within the treatment team as the client attempts to pit staff members
against each other. Consistent communication among the healthcare team is vital to
maintain boundaries and provide effective care.
,4. A nurse is admitting a client who has Anorexia Nervosa and is at 60% of their ideal body
weight. Which of the following interventions is the priority?
A. Initiating continuous cardiac monitoring
B. Setting a target weight for discharge
C. Encouraging the client to attend group therapy
D. Discussing the client’s body image perception
Correct Answer: A
Explanation: Clients with severe anorexia nervosa are at high risk for electrolyte
imbalances and cardiac arrhythmias due to starvation. Physical stabilization is the
immediate priority over psychological interventions when life-threatening physiological
symptoms are present. The nurse must monitor for bradycardia and QT interval
prolongation to prevent sudden cardiac arrest.
5. A nurse is educating the parents of a child with Conduct Disorder. Which of the following
characteristics should the nurse include in the teaching?
A. Excessive shyness in social situations
B. Fear of being separated from primary caregivers
C. Difficulty sustaining attention in class
D. Lack of remorse for violating the rights of others
Correct Answer: D
, Explanation: Conduct disorder involves a repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate societal norms are violated.
Children with this disorder often display aggression toward people and animals and show
little empathy or guilt for their actions. It is distinct from Oppositional Defiant Disorder,
which is characterized by defiance but generally lacks the severe aggression or theft seen in
Conduct Disorder.
6. A nurse is differentiating between delirium and dementia in an older adult client. Which of
the following features is unique to delirium?
A. Slow, progressive onset of memory loss
B. Irreversible cognitive decline
C. Difficulty with word-finding
D. Flat affect and social withdrawal
E. Presence of aphasia and apraxia
F. Altered level of consciousness that fluctuates
Correct Answer: F
Explanation: Delirium is characterized by a rapid onset and a fluctuating level of
consciousness, which is not typical of dementia. While dementia is a slow, progressive
decline, delirium is often caused by an underlying medical condition like an infection or
medication toxicity. Identifying the underlying cause is essential because delirium is
generally reversible once the cause is treated.
