Exam 3: NUR256 / NUR 256 (Latest 2025/ 2026 Update) Concepts of Mental
Health Nursing Guide| Questions & Answers| Grade A| 100% Correct (Verified
Solutions)- Galen
Question 1
A nurse is caring for a client with Borderline Personality Disorder (BPD). The client tells the
nurse, "The day shift nurse is so much better than you; she actually listens to me. You’re just
mean and don't care." The nurse should identify this as which defense mechanism?
A) Projection
B) Splitting
C) Reaction Formation
D) Rationalization
E) Undoing
Correct Answer: B) Splitting
Rationale: Splitting is a hallmark defense mechanism in clients with Borderline Personality
Disorder. It involves the inability to integrate positive and negative qualities of oneself or
others into a cohesive image. Individuals perceive others as "all good" or "all bad," which
often creates conflict among the nursing staff.
Question 2
A client is admitted for alcohol detoxification. Which of the following manifestations should the
nurse identify as a priority indicating the client is experiencing delirium tremens (DTs)?
A) Fine hand tremors and restlessness
B) Nausea and one episode of vomiting
C) Visual hallucinations and cardiac arrhythmias
D) Insomnia and irritability
E) Diaphoresis and a pulse rate of 98 bpm
Correct Answer: C) Visual hallucinations and cardiac arrhythmias
Rationale: Delirium Tremens (DTs) is a medical emergency that typically occurs 48 to 72
hours after the last drink. Characteristics include severe disorientation, psychotic
symptoms (hallucinations), severe hypertension, and cardiac dysrhythmias. Fine tremors
and nausea are symptoms of mild withdrawal, not delirium.
Question 3
A nurse is performing an admission assessment on a client with Anorexia Nervosa. Which of the
following physical findings should the nurse expect?
A) Tachycardia and hypertension
B) Amenorrhea and lanugo
C) Diarrhea and hyperthermia
D) Moist skin and hyperreflexia
E) Significant dental enamel erosion
Correct Answer: B) Amenorrhea and lanugo
Rationale: Clients with Anorexia Nervosa often present with amenorrhea (absence of
, 2
menstruation) due to low body weight and lanugo (fine, downy hair) as the body attempts
to insulate itself against heat loss. Enamel erosion (Option E) is more characteristic of
Bulimia Nervosa due to repetitive vomiting.
Question 4
An older adult client with Alzheimer’s disease becomes agitated and tries to leave the unit,
stating, "I need to go home and cook dinner for my husband." Which response by the nurse is the
most therapeutic?
A) "Your husband passed away ten years ago; you are in the hospital."
B) "You can't leave because the doors are locked for your safety."
C) "You are worried about your husband. Tell me what you used to cook for dinner."
D) "I will call the doctor to get you something to help you relax."
E) "Why do you think your husband is waiting for you at home?"
Correct Answer: C) "You are worried about your husband. Tell me what you used to cook
for dinner."
Rationale: This is an example of validation therapy and redirection. Rather than arguing
with the client's reality (which increases agitation), the nurse validates the underlying
emotion (concern for the husband) and redirects the client to a safe topic (memories of
cooking).
Question 5
A nurse is reinforcing teaching with the parent of a child newly diagnosed with ADHD and
prescribed methylphenidate. Which of the following instructions should the nurse include?
A) "Give the medication right before the child goes to bed."
B) "Administer the medication 30 minutes after dinner."
3) "Monitor your child's weight and height regularly."
D) "Avoid giving your child any protein while on this medication."
E) "Expect your child to have an increased appetite during the day."
Correct Answer: C) "Monitor your child's weight and height regularly."
Rationale: Methylphenidate is a CNS stimulant that often causes appetite suppression and
can lead to weight loss and growth retardation in children. Parents must track growth
patterns. It should be given in the morning to prevent insomnia, not at night.
Question 6
A client with Antisocial Personality Disorder is being treated in a group setting. During the
session, the client repeatedly interrupts and mocks other members. Which nursing intervention is
most appropriate?
A) Ignore the behavior to avoid giving the client attention.
B) Allow the group members to handle the behavior themselves.
C) Set clear limits on acceptable behavior and consequences.
D) Transfer the client to a different group immediately.
, 3
E) Ask the client why they feel the need to be disrespectful.
Correct Answer: C) Set clear limits on acceptable behavior and consequences.
Rationale: Clients with Antisocial Personality Disorder often disregard the rights of others
and lack remorse. The most effective nursing intervention is to establish firm, consistent
limits and clearly communicate the consequences for violating those limits.
Question 7
A nurse is caring for a client admitted with an opioid overdose. Which of the following
medications should the nurse expect to administer as the priority?
A) Methadone
B) Buprenorphine
C) Naloxone
D) Diazepam
E) Disulfiram
Correct Answer: C) Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse the effects of an opioid overdose,
particularly respiratory depression. It works quickly to displace opioids from receptor sites
and is the life-saving priority in acute toxicity.
Question 8
A client with Bulimia Nervosa is admitted to the psychiatric unit. Which nursing intervention is a
priority during the first 24 hours of admission?
A) Allow the client to eat alone in their room to reduce anxiety.
B) Observe the client during and for at least one hour after meals.
C) Weight the client once per week after the evening meal.
D) Limit the client's fluid intake to 1,000 mL per day.
E) Encourage the client to spend time in the bathroom to relax.
Correct Answer: B) Observe the client during and for at least one hour after meals.
Rationale: To prevent purging behaviors (vomiting or laxative use), the nurse must monitor
the client during meals and for a significant period afterward. This ensures the nutritional
intake is retained and provides an opportunity to support the client in managing the urge
to purge.
Question 9
An older adult client is brought to the Emergency Department by family members, who report a
sudden onset of confusion and disorientation over the last 6 hours. The nurse should suspect
which of the following?
A) Alzheimer’s disease
B) Vascular Dementia
C) Delirium
D) Depression
, 4
E) Wernicke-Korsakoff Syndrome
Correct Answer: C) Delirium
Rationale: Delirium is characterized by a rapid, acute onset of confusion, altered
consciousness, and fluctuating symptoms. Dementia (Alzheimer's or Vascular) is a slow,
progressive decline. Sudden changes in mental status are always treated as an acute
medical issue (Delirium).
Question 10
A nurse is caring for a client with Histrionic Personality Disorder. Which of the following
behaviors should the nurse expect?
A) Extreme suspiciousness and mistrust of others.
B) Social withdrawal and lack of interest in relationships.
C) Attention-seeking behavior and flamboyant clothing.
D) Perfectionism and preoccupation with details.
E) Fear of abandonment and self-harming behaviors.
Correct Answer: C) Attention-seeking behavior and flamboyant clothing.
Rationale: Histrionic Personality Disorder is characterized by a pervasive pattern of
excessive emotionality and attention-seeking. These individuals are often dramatic,
theatrical, and may use physical appearance or provocative behavior to draw attention to
themselves.
Question 11
A client has a new prescription for disulfiram. Which of the following statements by the client
indicates an understanding of the medication?
A) "I can still drink one glass of wine with dinner."
B) "I must avoid using mouthwash that contains alcohol."
C) "This medication will stop my cravings for alcohol."
D) "I only need to take this on days when I feel like drinking."
E) "It is safe to use alcohol-based hand sanitizer."
Correct Answer: B) "I must avoid using mouthwash that contains alcohol."
Rationale: Disulfiram (Antabuse) causes a severe physical reaction (nausea, vomiting,
tachycardia, hypotension) if any alcohol is ingested or absorbed through the skin. This
includes hidden sources of alcohol such as mouthwash, vanilla extract, and some cough
syrups.
Question 12
A nurse is assessing an adolescent with Conduct Disorder. Which of the following findings
should the nurse expect?
A) Excessive shyness and fear of being judged by others.
B) Persistent pattern of violating the rights of others and rules.
C) Repetitive motor tics and vocalizations.
Health Nursing Guide| Questions & Answers| Grade A| 100% Correct (Verified
Solutions)- Galen
Question 1
A nurse is caring for a client with Borderline Personality Disorder (BPD). The client tells the
nurse, "The day shift nurse is so much better than you; she actually listens to me. You’re just
mean and don't care." The nurse should identify this as which defense mechanism?
A) Projection
B) Splitting
C) Reaction Formation
D) Rationalization
E) Undoing
Correct Answer: B) Splitting
Rationale: Splitting is a hallmark defense mechanism in clients with Borderline Personality
Disorder. It involves the inability to integrate positive and negative qualities of oneself or
others into a cohesive image. Individuals perceive others as "all good" or "all bad," which
often creates conflict among the nursing staff.
Question 2
A client is admitted for alcohol detoxification. Which of the following manifestations should the
nurse identify as a priority indicating the client is experiencing delirium tremens (DTs)?
A) Fine hand tremors and restlessness
B) Nausea and one episode of vomiting
C) Visual hallucinations and cardiac arrhythmias
D) Insomnia and irritability
E) Diaphoresis and a pulse rate of 98 bpm
Correct Answer: C) Visual hallucinations and cardiac arrhythmias
Rationale: Delirium Tremens (DTs) is a medical emergency that typically occurs 48 to 72
hours after the last drink. Characteristics include severe disorientation, psychotic
symptoms (hallucinations), severe hypertension, and cardiac dysrhythmias. Fine tremors
and nausea are symptoms of mild withdrawal, not delirium.
Question 3
A nurse is performing an admission assessment on a client with Anorexia Nervosa. Which of the
following physical findings should the nurse expect?
A) Tachycardia and hypertension
B) Amenorrhea and lanugo
C) Diarrhea and hyperthermia
D) Moist skin and hyperreflexia
E) Significant dental enamel erosion
Correct Answer: B) Amenorrhea and lanugo
Rationale: Clients with Anorexia Nervosa often present with amenorrhea (absence of
, 2
menstruation) due to low body weight and lanugo (fine, downy hair) as the body attempts
to insulate itself against heat loss. Enamel erosion (Option E) is more characteristic of
Bulimia Nervosa due to repetitive vomiting.
Question 4
An older adult client with Alzheimer’s disease becomes agitated and tries to leave the unit,
stating, "I need to go home and cook dinner for my husband." Which response by the nurse is the
most therapeutic?
A) "Your husband passed away ten years ago; you are in the hospital."
B) "You can't leave because the doors are locked for your safety."
C) "You are worried about your husband. Tell me what you used to cook for dinner."
D) "I will call the doctor to get you something to help you relax."
E) "Why do you think your husband is waiting for you at home?"
Correct Answer: C) "You are worried about your husband. Tell me what you used to cook
for dinner."
Rationale: This is an example of validation therapy and redirection. Rather than arguing
with the client's reality (which increases agitation), the nurse validates the underlying
emotion (concern for the husband) and redirects the client to a safe topic (memories of
cooking).
Question 5
A nurse is reinforcing teaching with the parent of a child newly diagnosed with ADHD and
prescribed methylphenidate. Which of the following instructions should the nurse include?
A) "Give the medication right before the child goes to bed."
B) "Administer the medication 30 minutes after dinner."
3) "Monitor your child's weight and height regularly."
D) "Avoid giving your child any protein while on this medication."
E) "Expect your child to have an increased appetite during the day."
Correct Answer: C) "Monitor your child's weight and height regularly."
Rationale: Methylphenidate is a CNS stimulant that often causes appetite suppression and
can lead to weight loss and growth retardation in children. Parents must track growth
patterns. It should be given in the morning to prevent insomnia, not at night.
Question 6
A client with Antisocial Personality Disorder is being treated in a group setting. During the
session, the client repeatedly interrupts and mocks other members. Which nursing intervention is
most appropriate?
A) Ignore the behavior to avoid giving the client attention.
B) Allow the group members to handle the behavior themselves.
C) Set clear limits on acceptable behavior and consequences.
D) Transfer the client to a different group immediately.
, 3
E) Ask the client why they feel the need to be disrespectful.
Correct Answer: C) Set clear limits on acceptable behavior and consequences.
Rationale: Clients with Antisocial Personality Disorder often disregard the rights of others
and lack remorse. The most effective nursing intervention is to establish firm, consistent
limits and clearly communicate the consequences for violating those limits.
Question 7
A nurse is caring for a client admitted with an opioid overdose. Which of the following
medications should the nurse expect to administer as the priority?
A) Methadone
B) Buprenorphine
C) Naloxone
D) Diazepam
E) Disulfiram
Correct Answer: C) Naloxone
Rationale: Naloxone is an opioid antagonist used to reverse the effects of an opioid overdose,
particularly respiratory depression. It works quickly to displace opioids from receptor sites
and is the life-saving priority in acute toxicity.
Question 8
A client with Bulimia Nervosa is admitted to the psychiatric unit. Which nursing intervention is a
priority during the first 24 hours of admission?
A) Allow the client to eat alone in their room to reduce anxiety.
B) Observe the client during and for at least one hour after meals.
C) Weight the client once per week after the evening meal.
D) Limit the client's fluid intake to 1,000 mL per day.
E) Encourage the client to spend time in the bathroom to relax.
Correct Answer: B) Observe the client during and for at least one hour after meals.
Rationale: To prevent purging behaviors (vomiting or laxative use), the nurse must monitor
the client during meals and for a significant period afterward. This ensures the nutritional
intake is retained and provides an opportunity to support the client in managing the urge
to purge.
Question 9
An older adult client is brought to the Emergency Department by family members, who report a
sudden onset of confusion and disorientation over the last 6 hours. The nurse should suspect
which of the following?
A) Alzheimer’s disease
B) Vascular Dementia
C) Delirium
D) Depression
, 4
E) Wernicke-Korsakoff Syndrome
Correct Answer: C) Delirium
Rationale: Delirium is characterized by a rapid, acute onset of confusion, altered
consciousness, and fluctuating symptoms. Dementia (Alzheimer's or Vascular) is a slow,
progressive decline. Sudden changes in mental status are always treated as an acute
medical issue (Delirium).
Question 10
A nurse is caring for a client with Histrionic Personality Disorder. Which of the following
behaviors should the nurse expect?
A) Extreme suspiciousness and mistrust of others.
B) Social withdrawal and lack of interest in relationships.
C) Attention-seeking behavior and flamboyant clothing.
D) Perfectionism and preoccupation with details.
E) Fear of abandonment and self-harming behaviors.
Correct Answer: C) Attention-seeking behavior and flamboyant clothing.
Rationale: Histrionic Personality Disorder is characterized by a pervasive pattern of
excessive emotionality and attention-seeking. These individuals are often dramatic,
theatrical, and may use physical appearance or provocative behavior to draw attention to
themselves.
Question 11
A client has a new prescription for disulfiram. Which of the following statements by the client
indicates an understanding of the medication?
A) "I can still drink one glass of wine with dinner."
B) "I must avoid using mouthwash that contains alcohol."
C) "This medication will stop my cravings for alcohol."
D) "I only need to take this on days when I feel like drinking."
E) "It is safe to use alcohol-based hand sanitizer."
Correct Answer: B) "I must avoid using mouthwash that contains alcohol."
Rationale: Disulfiram (Antabuse) causes a severe physical reaction (nausea, vomiting,
tachycardia, hypotension) if any alcohol is ingested or absorbed through the skin. This
includes hidden sources of alcohol such as mouthwash, vanilla extract, and some cough
syrups.
Question 12
A nurse is assessing an adolescent with Conduct Disorder. Which of the following findings
should the nurse expect?
A) Excessive shyness and fear of being judged by others.
B) Persistent pattern of violating the rights of others and rules.
C) Repetitive motor tics and vocalizations.
