PRN 1562/PRN1562 Exam 3 V1 | Principles
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder who alternates between
overvaluing and undervaluing staff members. Which defense mechanism should the nurse
document?
A. Reaction Formation
B. Splitting
C. Projection
D. Rationalization
Correct Answer: B
Expert Explanation: Splitting is the primary defense mechanism used by individuals with
Borderline Personality Disorder to manage anxiety. It involves the inability to integrate
positive and negative qualities of oneself or others into a cohesive image. This behavior
frequently causes conflict among the nursing staff as the client treats some as heroes and
others as villains.
2. An adolescent client is admitted with a diagnosis of Anorexia Nervosa. Which assessment
finding is the most critical for the nurse to address immediately?
A. Potassium level of 2.8 mEq/L
,B. Amenorrhea for six months
C. Lanugo on the back and arms
D. Body weight 25% below ideal
Correct Answer: A
Expert Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which
poses an immediate risk for cardiac dysrhythmias and arrest. While weight loss and lanugo
are characteristic of anorexia, they are not immediately life-threatening. Electrolyte
stabilization is the highest priority during the initial phase of treatment.
3. A client with Bipolar I Disorder is in the middle of a severe manic episode. Which
nutritional intervention is most appropriate?
A. Allowing the client to eat in the main dining hall
B. Providing high-calorie finger foods
C. Serving a three-course sit-down meal
D. Encouraging the use of a spoon and fork
Correct Answer: B
Expert Explanation: Clients in a manic state are often too hyperactive to sit down for a full
meal. High-calorie finger foods allow the client to maintain nutrition while on the move or
pacing. This strategy helps prevent exhaustion and significant weight loss during the manic
phase.
, 4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value requires immediate notification to the healthcare provider?
A. Serum Lithium level of 1.2 mEq/L
B. WBC count of 8,000/mm3
C. Sodium level of 138 mEq/L
D. Serum Lithium level of 1.8 mEq/L
Correct Answer: D
Expert Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range and
indicates moderate toxicity. The therapeutic range is typically 0.6 to 1.2 mEq/L for
maintenance and up to 1.5 mEq/L for acute mania. Levels above 1.5 mEq/L can lead to
serious complications like tremors, confusion, and seizures.
5. A client with Antisocial Personality Disorder is repeatedly asking for special privileges and
trying to bypass unit rules. How should the nurse respond?
A. Allow the request once to build rapport
B. Discuss the requests during the next group therapy session
C. Firmly and consistently reinforce the established unit rules
D. Ask the client why they feel they deserve special treatment
Correct Answer: C
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder who alternates between
overvaluing and undervaluing staff members. Which defense mechanism should the nurse
document?
A. Reaction Formation
B. Splitting
C. Projection
D. Rationalization
Correct Answer: B
Expert Explanation: Splitting is the primary defense mechanism used by individuals with
Borderline Personality Disorder to manage anxiety. It involves the inability to integrate
positive and negative qualities of oneself or others into a cohesive image. This behavior
frequently causes conflict among the nursing staff as the client treats some as heroes and
others as villains.
2. An adolescent client is admitted with a diagnosis of Anorexia Nervosa. Which assessment
finding is the most critical for the nurse to address immediately?
A. Potassium level of 2.8 mEq/L
,B. Amenorrhea for six months
C. Lanugo on the back and arms
D. Body weight 25% below ideal
Correct Answer: A
Expert Explanation: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which
poses an immediate risk for cardiac dysrhythmias and arrest. While weight loss and lanugo
are characteristic of anorexia, they are not immediately life-threatening. Electrolyte
stabilization is the highest priority during the initial phase of treatment.
3. A client with Bipolar I Disorder is in the middle of a severe manic episode. Which
nutritional intervention is most appropriate?
A. Allowing the client to eat in the main dining hall
B. Providing high-calorie finger foods
C. Serving a three-course sit-down meal
D. Encouraging the use of a spoon and fork
Correct Answer: B
Expert Explanation: Clients in a manic state are often too hyperactive to sit down for a full
meal. High-calorie finger foods allow the client to maintain nutrition while on the move or
pacing. This strategy helps prevent exhaustion and significant weight loss during the manic
phase.
, 4. A client is prescribed Lithium Carbonate for the treatment of Bipolar Disorder. Which
laboratory value requires immediate notification to the healthcare provider?
A. Serum Lithium level of 1.2 mEq/L
B. WBC count of 8,000/mm3
C. Sodium level of 138 mEq/L
D. Serum Lithium level of 1.8 mEq/L
Correct Answer: D
Expert Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range and
indicates moderate toxicity. The therapeutic range is typically 0.6 to 1.2 mEq/L for
maintenance and up to 1.5 mEq/L for acute mania. Levels above 1.5 mEq/L can lead to
serious complications like tremors, confusion, and seizures.
5. A client with Antisocial Personality Disorder is repeatedly asking for special privileges and
trying to bypass unit rules. How should the nurse respond?
A. Allow the request once to build rapport
B. Discuss the requests during the next group therapy session
C. Firmly and consistently reinforce the established unit rules
D. Ask the client why they feel they deserve special treatment
Correct Answer: C
