NUR2459/NUR 2459 Exam 3 V2 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A client experiencing a panic attack is hyperventilating and feels a sense of impending
doom. Which action should the nurse take first?
A. Stay with the client and use a calm, low-pitched voice.
B. Provide a high-stimulation environment to distract the client.
C. Ask the client to describe their feelings in detail.
D. Instruct the client to go for a brisk walk around the unit.
Correct Answer: A
Expert Explanation: Safety and presence are the priorities during a panic attack. The
nurse’s calm demeanor helps the client feel grounded and secure. Providing reassurance in
a low-pitched voice minimizes further stimulation and panic escalation.
2. Which assessment finding is most characteristic of a client with Anorexia Nervosa?
A. High potassium levels and weight gain.
B. Body weight less than 85% of expected norms.
C. Normal electrolyte balance and high BMI.
,D. Absence of obsession with food or calories.
Correct Answer: B
Expert Explanation: Anorexia Nervosa is defined by a refusal to maintain a minimally
normal body weight. This often results in a BMI significantly lower than the expected range
for the client’s age and height. The condition involves an intense fear of gaining weight and
a distorted body image.
3. A client with Obsessive-Compulsive Disorder (OCD) spends hours washing their hands.
What is the initial nursing intervention?
A. Strictly forbid the handwashing rituals immediately.
B. Allow the client time for the ritual initially while setting limits.
C. Confront the client about the irrationality of the behavior.
D. Administer a sedative to keep the client from washing.
Correct Answer: B
Expert Explanation: Stopping a ritual abruptly can cause overwhelming anxiety for a
client with OCD. Initially, the nurse should allow the ritual to occur but gradually negotiate
time limits as the plan of care progresses. This approach fosters trust and reduces the risk
of an acute panic response.
4. A child is diagnosed with Oppositional Defiant Disorder (ODD). Which behavior is typical of
this diagnosis?
A. Argumentative behavior toward authority figures.
, B. Physical cruelty to animals and arson.
C. Complete lack of verbal communication with others.
D. Engaging in repetitive motor movements like hand flapping.
Correct Answer: A
Expert Explanation: Oppositional Defiant Disorder is characterized by a pattern of angry
or irritable moods and argumentative behavior. Clients with ODD typically direct their
defiance toward authority figures such as parents or teachers. Unlike conduct disorder,
ODD does not usually involve severe violations of the rights of others.
5. The nurse is caring for a client with Borderline Personality Disorder. The client states, ‘One
nurse is wonderful, but the other nurse is terrible.’ This is an example of which defense
mechanism?
A. Sublimation
B. Splitting
C. Reaction Formation
D. Intellectualization
Correct Answer: B
Expert Explanation: Splitting is a common defense mechanism in clients with Borderline
Personality Disorder where they see people as all good or all bad. This inability to integrate
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A client experiencing a panic attack is hyperventilating and feels a sense of impending
doom. Which action should the nurse take first?
A. Stay with the client and use a calm, low-pitched voice.
B. Provide a high-stimulation environment to distract the client.
C. Ask the client to describe their feelings in detail.
D. Instruct the client to go for a brisk walk around the unit.
Correct Answer: A
Expert Explanation: Safety and presence are the priorities during a panic attack. The
nurse’s calm demeanor helps the client feel grounded and secure. Providing reassurance in
a low-pitched voice minimizes further stimulation and panic escalation.
2. Which assessment finding is most characteristic of a client with Anorexia Nervosa?
A. High potassium levels and weight gain.
B. Body weight less than 85% of expected norms.
C. Normal electrolyte balance and high BMI.
,D. Absence of obsession with food or calories.
Correct Answer: B
Expert Explanation: Anorexia Nervosa is defined by a refusal to maintain a minimally
normal body weight. This often results in a BMI significantly lower than the expected range
for the client’s age and height. The condition involves an intense fear of gaining weight and
a distorted body image.
3. A client with Obsessive-Compulsive Disorder (OCD) spends hours washing their hands.
What is the initial nursing intervention?
A. Strictly forbid the handwashing rituals immediately.
B. Allow the client time for the ritual initially while setting limits.
C. Confront the client about the irrationality of the behavior.
D. Administer a sedative to keep the client from washing.
Correct Answer: B
Expert Explanation: Stopping a ritual abruptly can cause overwhelming anxiety for a
client with OCD. Initially, the nurse should allow the ritual to occur but gradually negotiate
time limits as the plan of care progresses. This approach fosters trust and reduces the risk
of an acute panic response.
4. A child is diagnosed with Oppositional Defiant Disorder (ODD). Which behavior is typical of
this diagnosis?
A. Argumentative behavior toward authority figures.
, B. Physical cruelty to animals and arson.
C. Complete lack of verbal communication with others.
D. Engaging in repetitive motor movements like hand flapping.
Correct Answer: A
Expert Explanation: Oppositional Defiant Disorder is characterized by a pattern of angry
or irritable moods and argumentative behavior. Clients with ODD typically direct their
defiance toward authority figures such as parents or teachers. Unlike conduct disorder,
ODD does not usually involve severe violations of the rights of others.
5. The nurse is caring for a client with Borderline Personality Disorder. The client states, ‘One
nurse is wonderful, but the other nurse is terrible.’ This is an example of which defense
mechanism?
A. Sublimation
B. Splitting
C. Reaction Formation
D. Intellectualization
Correct Answer: B
Expert Explanation: Splitting is a common defense mechanism in clients with Borderline
Personality Disorder where they see people as all good or all bad. This inability to integrate
