NUR2459/NUR 2459 Exam 3 V1 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder who is using splitting.
Which action should the nurse take?
A. Hold a staff meeting to ensure a consistent approach by all team members.
B. Allow the client to choose which nurse they want to work with.
C. Encourage the client to express their feelings to the nurse they dislike.
D. Discuss the client’s behavior with other clients to gain perspective.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad. This behavior often leads to conflict among staff members and
inconsistent care. By holding a staff meeting, the team can ensure a unified approach, which
is the most effective way to manage this behavior.
2. Which assessment finding is most characteristic of a client with Antisocial Personality
Disorder?
A. Extreme sensitivity to rejection and social withdrawal.
,B. Lack of remorse for actions that hurt others.
C. Excessive emotionality and attention-seeking behavior.
D. Preoccupation with orderliness and perfectionism.
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is marked by a pervasive pattern of
disregard for the rights of others. Individuals often engage in illegal acts and show a
profound lack of guilt or remorse for their conduct. They tend to be manipulative and may
appear charming to achieve their personal goals.
3. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering first to prevent seizures?
A. Disulfiram
B. Lorazepam
C. Fluoxetine
D. Naltrexone
Correct Answer: B
Expert Explanation: Benzodiazepines like Lorazepam are the gold standard for managing
acute alcohol withdrawal symptoms. They help stabilize vital signs and reduce the risk of
withdrawal-related seizures or delirium tremens. Other medications like Disulfiram are
used for long-term maintenance rather than acute detox.
, 4. A nurse is assessing a client with Anorexia Nervosa. Which physical finding is expected?
A. Lanugo
B. Tachycardia
C. Hypertension
D. Hyperthermia
Correct Answer: A
Expert Explanation: Lanugo is the growth of fine, downy hair on the body as a
compensatory mechanism to provide warmth due to the loss of subcutaneous fat. Clients
with anorexia often exhibit bradycardia and hypotension rather than tachycardia and
hypertension. Hypothermia is also common because the body struggles to maintain its core
temperature.
5. What is the primary purpose of the Clinical Institute Withdrawal Assessment (CIWA-Ar)
scale?
A. To determine the severity of alcohol withdrawal symptoms.
B. To diagnose the underlying cause of alcoholism.
C. To measure the blood alcohol concentration.
D. To predict the success of long-term sobriety.
Correct Answer: A
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder who is using splitting.
Which action should the nurse take?
A. Hold a staff meeting to ensure a consistent approach by all team members.
B. Allow the client to choose which nurse they want to work with.
C. Encourage the client to express their feelings to the nurse they dislike.
D. Discuss the client’s behavior with other clients to gain perspective.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad. This behavior often leads to conflict among staff members and
inconsistent care. By holding a staff meeting, the team can ensure a unified approach, which
is the most effective way to manage this behavior.
2. Which assessment finding is most characteristic of a client with Antisocial Personality
Disorder?
A. Extreme sensitivity to rejection and social withdrawal.
,B. Lack of remorse for actions that hurt others.
C. Excessive emotionality and attention-seeking behavior.
D. Preoccupation with orderliness and perfectionism.
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is marked by a pervasive pattern of
disregard for the rights of others. Individuals often engage in illegal acts and show a
profound lack of guilt or remorse for their conduct. They tend to be manipulative and may
appear charming to achieve their personal goals.
3. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering first to prevent seizures?
A. Disulfiram
B. Lorazepam
C. Fluoxetine
D. Naltrexone
Correct Answer: B
Expert Explanation: Benzodiazepines like Lorazepam are the gold standard for managing
acute alcohol withdrawal symptoms. They help stabilize vital signs and reduce the risk of
withdrawal-related seizures or delirium tremens. Other medications like Disulfiram are
used for long-term maintenance rather than acute detox.
, 4. A nurse is assessing a client with Anorexia Nervosa. Which physical finding is expected?
A. Lanugo
B. Tachycardia
C. Hypertension
D. Hyperthermia
Correct Answer: A
Expert Explanation: Lanugo is the growth of fine, downy hair on the body as a
compensatory mechanism to provide warmth due to the loss of subcutaneous fat. Clients
with anorexia often exhibit bradycardia and hypotension rather than tachycardia and
hypertension. Hypothermia is also common because the body struggles to maintain its core
temperature.
5. What is the primary purpose of the Clinical Institute Withdrawal Assessment (CIWA-Ar)
scale?
A. To determine the severity of alcohol withdrawal symptoms.
B. To diagnose the underlying cause of alcoholism.
C. To measure the blood alcohol concentration.
D. To predict the success of long-term sobriety.
Correct Answer: A
