NUR2459/NUR 2459 Exam 4 V1 |
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A client with Borderline Personality Disorder is observed being extremely friendly with one
nurse while disparaging another nurse to their face. This behavior is best described as:
A. Projection
B. Splitting
C. Reaction Formation
D. Rationalization
Correct Answer: B
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where the client views others as all good or all bad. It serves to protect the
individual from the complexity of human relationships and internal conflict. The nursing
staff should maintain consistent communication and firm boundaries to minimize the
impact of this behavior.
2. When assessing a client with Antisocial Personality Disorder, which clinical finding is the
nurse most likely to encounter?
A. Excessive guilt and remorse for past actions
,B. Lack of remorse and disregard for the rights of others
C. High levels of empathy for others
D. Social withdrawal and intense shyness
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is characterized by a pervasive
pattern of disregard for and violation of the rights of others. These individuals often lack
remorse for their harmful actions and may manipulate others for personal gain.
Interventions should focus on setting clear limits on behavior and promoting
accountability.
3. A client is admitted for treatment of Anorexia Nervosa. Which physical assessment finding
is most characteristic of this disorder?
A. Hypertension and tachycardia
B. Increased muscle mass and hyperreflexia
C. Hyperthermia and oily skin
D. Lanugo and bradycardia
Correct Answer: D
Expert Explanation: Anorexia Nervosa often leads to physiological adaptations to
starvation, such as lanugo, which is fine, downy hair growth on the body. Clients also
frequently experience bradycardia and hypotension as the body attempts to conserve
, energy. Close monitoring of vital signs is essential due to the high risk of cardiac
complications.
4. A nurse is caring for a client with Bulimia Nervosa. The nurse notes calluses on the knuckles
of the client’s hand. This is known as:
A. Chvostek’s sign
B. Trousseau’s sign
C. Homan’s sign
D. Russell’s sign
Correct Answer: D
Expert Explanation: Russell’s sign refers to the calluses or scars on the knuckles caused by
repeated self-induced vomiting. It is a key physical indicator that suggests the client is
engaging in purging behaviors. The nurse should assess the oral cavity and electrolyte
levels for further complications related to purging.
5. A client who has been drinking alcohol daily for several years is admitted to the hospital.
Which symptom should the nurse prioritize as an early sign of alcohol withdrawal?
A. Bradycardia and somnolence
B. Euphoria and increased appetite
C. Hypotension and dry mouth
D. Tremors and tachycardia
Mental and Behavioral Health
Nursing Q&A with Rationale |
Rasmussen University
1. A client with Borderline Personality Disorder is observed being extremely friendly with one
nurse while disparaging another nurse to their face. This behavior is best described as:
A. Projection
B. Splitting
C. Reaction Formation
D. Rationalization
Correct Answer: B
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where the client views others as all good or all bad. It serves to protect the
individual from the complexity of human relationships and internal conflict. The nursing
staff should maintain consistent communication and firm boundaries to minimize the
impact of this behavior.
2. When assessing a client with Antisocial Personality Disorder, which clinical finding is the
nurse most likely to encounter?
A. Excessive guilt and remorse for past actions
,B. Lack of remorse and disregard for the rights of others
C. High levels of empathy for others
D. Social withdrawal and intense shyness
Correct Answer: B
Expert Explanation: Antisocial Personality Disorder is characterized by a pervasive
pattern of disregard for and violation of the rights of others. These individuals often lack
remorse for their harmful actions and may manipulate others for personal gain.
Interventions should focus on setting clear limits on behavior and promoting
accountability.
3. A client is admitted for treatment of Anorexia Nervosa. Which physical assessment finding
is most characteristic of this disorder?
A. Hypertension and tachycardia
B. Increased muscle mass and hyperreflexia
C. Hyperthermia and oily skin
D. Lanugo and bradycardia
Correct Answer: D
Expert Explanation: Anorexia Nervosa often leads to physiological adaptations to
starvation, such as lanugo, which is fine, downy hair growth on the body. Clients also
frequently experience bradycardia and hypotension as the body attempts to conserve
, energy. Close monitoring of vital signs is essential due to the high risk of cardiac
complications.
4. A nurse is caring for a client with Bulimia Nervosa. The nurse notes calluses on the knuckles
of the client’s hand. This is known as:
A. Chvostek’s sign
B. Trousseau’s sign
C. Homan’s sign
D. Russell’s sign
Correct Answer: D
Expert Explanation: Russell’s sign refers to the calluses or scars on the knuckles caused by
repeated self-induced vomiting. It is a key physical indicator that suggests the client is
engaging in purging behaviors. The nurse should assess the oral cavity and electrolyte
levels for further complications related to purging.
5. A client who has been drinking alcohol daily for several years is admitted to the hospital.
Which symptom should the nurse prioritize as an early sign of alcohol withdrawal?
A. Bradycardia and somnolence
B. Euphoria and increased appetite
C. Hypotension and dry mouth
D. Tremors and tachycardia
