NUR2459 Exam 3 Actual Exam Style V3 |
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with anorexia nervosa who has a body mass index (BMI) of 14.
Which of the following is the priority nursing intervention?
A. Encouraging the client to express feelings about body image
B. Initiating continuous cardiac monitoring
C. Developing a high-calorie meal plan with the dietician
D. Teaching the client about the long-term effects of malnutrition
Correct Answer: B
Expert Explanation: Clients with severe anorexia nervosa and extremely low BMI are at
high risk for electrolyte imbalances and cardiac arrhythmias. Continuous cardiac
monitoring is essential because bradycardia and QT interval prolongation can lead to
sudden cardiac arrest. While nutrition and therapy are important, physiological stability
takes priority in an acute care setting.
2. A client is admitted for alcohol withdrawal and is experiencing tremors, diaphoresis, and a
heart rate of 110 bpm. Which medication should the nurse expect to administer?
A. Disulfiram
B. Naltrexone
C. Lorazepam
,D. Methadone
Correct Answer: C
Expert Explanation: Benzodiazepines like lorazepam are the first-line treatment for
managing acute alcohol withdrawal symptoms. They help prevent the progression to
seizures and delirium tremens by providing cross-tolerance with alcohol. Disulfiram and
naltrexone are used for long-term maintenance of sobriety, not acute withdrawal
management.
3. A nurse is assessing a child with a diagnosis of Conduct Disorder. Which behavior is most
characteristic of this condition?
A. Frequent temper tantrums when asked to do chores
B. Physical aggression toward animals and peers
C. Difficulty sustaining attention in the classroom
D. Repetitive motor movements like hand-flapping
Correct Answer: B
Expert Explanation: Conduct Disorder is characterized by a persistent pattern of behavior
that violates the basic rights of others or major age-appropriate societal norms. This often
includes physical aggression, cruelty to animals, and destruction of property. It is more
severe than Oppositional Defiant Disorder, which typically involves verbal defiance rather
than physical harm.
, 4. A client with Borderline Personality Disorder (BPD) tells a nurse, ‘The day shift nurse is an
angel, but the night shift nurse is mean and incompetent.’ The nurse should recognize this as:
A. Altruism
B. Reaction formation
C. Projection
D. Splitting
Correct Answer: D
Expert Explanation: Splitting is a primary defense mechanism used by individuals with
Borderline Personality Disorder where they view people as either all good or all bad. This
behavior often creates conflict among the nursing staff and disrupts the therapeutic
environment. The nurse should respond by maintaining consistent boundaries and
communicating clearly with the rest of the treatment team.
5. An elderly client is brought to the emergency department with acute confusion, visual
hallucinations, and a fluctuating level of consciousness. Which condition is the client likely
experiencing?
A. Alzheimer’s Disease
B. Depression
C. Vascular Dementia
D. Delirium
NUR 2459 Mental and Behavioral Health
Nursing | Rasmussen
1. A nurse is caring for a client with anorexia nervosa who has a body mass index (BMI) of 14.
Which of the following is the priority nursing intervention?
A. Encouraging the client to express feelings about body image
B. Initiating continuous cardiac monitoring
C. Developing a high-calorie meal plan with the dietician
D. Teaching the client about the long-term effects of malnutrition
Correct Answer: B
Expert Explanation: Clients with severe anorexia nervosa and extremely low BMI are at
high risk for electrolyte imbalances and cardiac arrhythmias. Continuous cardiac
monitoring is essential because bradycardia and QT interval prolongation can lead to
sudden cardiac arrest. While nutrition and therapy are important, physiological stability
takes priority in an acute care setting.
2. A client is admitted for alcohol withdrawal and is experiencing tremors, diaphoresis, and a
heart rate of 110 bpm. Which medication should the nurse expect to administer?
A. Disulfiram
B. Naltrexone
C. Lorazepam
,D. Methadone
Correct Answer: C
Expert Explanation: Benzodiazepines like lorazepam are the first-line treatment for
managing acute alcohol withdrawal symptoms. They help prevent the progression to
seizures and delirium tremens by providing cross-tolerance with alcohol. Disulfiram and
naltrexone are used for long-term maintenance of sobriety, not acute withdrawal
management.
3. A nurse is assessing a child with a diagnosis of Conduct Disorder. Which behavior is most
characteristic of this condition?
A. Frequent temper tantrums when asked to do chores
B. Physical aggression toward animals and peers
C. Difficulty sustaining attention in the classroom
D. Repetitive motor movements like hand-flapping
Correct Answer: B
Expert Explanation: Conduct Disorder is characterized by a persistent pattern of behavior
that violates the basic rights of others or major age-appropriate societal norms. This often
includes physical aggression, cruelty to animals, and destruction of property. It is more
severe than Oppositional Defiant Disorder, which typically involves verbal defiance rather
than physical harm.
, 4. A client with Borderline Personality Disorder (BPD) tells a nurse, ‘The day shift nurse is an
angel, but the night shift nurse is mean and incompetent.’ The nurse should recognize this as:
A. Altruism
B. Reaction formation
C. Projection
D. Splitting
Correct Answer: D
Expert Explanation: Splitting is a primary defense mechanism used by individuals with
Borderline Personality Disorder where they view people as either all good or all bad. This
behavior often creates conflict among the nursing staff and disrupts the therapeutic
environment. The nurse should respond by maintaining consistent boundaries and
communicating clearly with the rest of the treatment team.
5. An elderly client is brought to the emergency department with acute confusion, visual
hallucinations, and a fluctuating level of consciousness. Which condition is the client likely
experiencing?
A. Alzheimer’s Disease
B. Depression
C. Vascular Dementia
D. Delirium
