NUR2459/NUR 2459 Exam 4 V2 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a child with ADHD who is prescribed methylphenidate. Which side
effect should the nurse prioritize for teaching?
A. Insomnia and weight loss
B. Increased appetite and sedation
C. Excessive weight gain and lethargy
D. Bradycardia and hypotension
Correct Answer: A
Expert Explanation: Methylphenidate is a central nervous system stimulant that can cause
significant appetite suppression and difficulty falling asleep. Monitoring growth
parameters and establishing a morning dosing schedule are critical nursing interventions.
Parents should be educated on managing these effects to ensure the child maintains
adequate nutrition.
2. Which developmental milestone is most commonly delayed or absent in children
diagnosed with Autism Spectrum Disorder (ASD)?
A. Social-emotional reciprocity
,B. Gross motor skills like walking
C. Ability to swallow solid foods
D. Hearing and visual acuity
Correct Answer: A
Expert Explanation: ASD is primarily characterized by deficits in social communication
and social interaction across multiple contexts. Children often struggle with back-and-forth
conversation or sharing emotions with others. Early intervention focuses on improving
these social skills to enhance the child’s quality of life.
3. A client with Anorexia Nervosa has a BMI of 14. Which nursing diagnosis takes the highest
priority during the acute phase of treatment?
A. Imbalanced Nutrition: Less Than Body Requirements
B. Chronic Low Self-Esteem
C. Ineffective Coping
D. Disturbed Body Image
Correct Answer: A
Expert Explanation: Physiological stability is always the priority in a client with severe
malnutrition and low BMI. The body is at risk for multisystem failure, including cardiac
arrhythmias and electrolyte imbalances. Once the client is medically stabilized, the
psychological aspects of the disorder can be more effectively addressed.
, 4. A client with Bulimia Nervosa is found to have calluses on the knuckles of the hand. How
should the nurse document this finding?
A. Russell’s sign
B. Chvostek’s sign
C. Trousseau’s sign
D. Homans’ sign
Correct Answer: A
Expert Explanation: Russell’s sign is caused by repeated trauma to the hand from the
teeth during self-induced vomiting. This physical finding is a hallmark clinical indicator of
purging behavior. The nurse should use this assessment to further explore the client’s
eating habits and purging frequency.
5. A client with Borderline Personality Disorder (BPD) tells a nurse, ‘You are the only one who
cares, but that other nurse is mean.’ This is an example of:
A. Idealization
B. Splitting
C. Projection
D. Rationalization
Correct Answer: B
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A nurse is assessing a child with ADHD who is prescribed methylphenidate. Which side
effect should the nurse prioritize for teaching?
A. Insomnia and weight loss
B. Increased appetite and sedation
C. Excessive weight gain and lethargy
D. Bradycardia and hypotension
Correct Answer: A
Expert Explanation: Methylphenidate is a central nervous system stimulant that can cause
significant appetite suppression and difficulty falling asleep. Monitoring growth
parameters and establishing a morning dosing schedule are critical nursing interventions.
Parents should be educated on managing these effects to ensure the child maintains
adequate nutrition.
2. Which developmental milestone is most commonly delayed or absent in children
diagnosed with Autism Spectrum Disorder (ASD)?
A. Social-emotional reciprocity
,B. Gross motor skills like walking
C. Ability to swallow solid foods
D. Hearing and visual acuity
Correct Answer: A
Expert Explanation: ASD is primarily characterized by deficits in social communication
and social interaction across multiple contexts. Children often struggle with back-and-forth
conversation or sharing emotions with others. Early intervention focuses on improving
these social skills to enhance the child’s quality of life.
3. A client with Anorexia Nervosa has a BMI of 14. Which nursing diagnosis takes the highest
priority during the acute phase of treatment?
A. Imbalanced Nutrition: Less Than Body Requirements
B. Chronic Low Self-Esteem
C. Ineffective Coping
D. Disturbed Body Image
Correct Answer: A
Expert Explanation: Physiological stability is always the priority in a client with severe
malnutrition and low BMI. The body is at risk for multisystem failure, including cardiac
arrhythmias and electrolyte imbalances. Once the client is medically stabilized, the
psychological aspects of the disorder can be more effectively addressed.
, 4. A client with Bulimia Nervosa is found to have calluses on the knuckles of the hand. How
should the nurse document this finding?
A. Russell’s sign
B. Chvostek’s sign
C. Trousseau’s sign
D. Homans’ sign
Correct Answer: A
Expert Explanation: Russell’s sign is caused by repeated trauma to the hand from the
teeth during self-induced vomiting. This physical finding is a hallmark clinical indicator of
purging behavior. The nurse should use this assessment to further explore the client’s
eating habits and purging frequency.
5. A client with Borderline Personality Disorder (BPD) tells a nurse, ‘You are the only one who
cares, but that other nurse is mean.’ This is an example of:
A. Idealization
B. Splitting
C. Projection
D. Rationalization
Correct Answer: B
