PRN 1562/PRN1562 Exam 4 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 is using splitting.
Which action should the nurse take?
A. Maintain consistent boundaries and communicate with the treatment team.
B. Allow the client to choose their primary nurse daily.
C. Ignore the behavior to avoid reinforcing it.
D. Provide the client with extra attention to build rapport.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad. Consistency among the staff is crucial to prevent the client from
playing staff members against each other. Clear communication within the treatment team
ensures that everyone follows the same care plan and maintains professional boundaries.
2. A client with Anorexia Nervosa is admitted to the unit. Which of the following physical
findings is the nurse’s priority?
A. Heart rate of 38 beats per minute.
B. Report of amenorrhea for six months.
C. Presence of lanugo on the back and arms.
,D. Dry, flaky skin and brittle nails.
Correct Answer: A
Expert Explanation: A heart rate of 38 bpm indicates severe bradycardia, which is a
medical emergency. Physiological stability must be addressed before psychological issues
according to the ABCs and Maslow’s hierarchy. The nurse must monitor for cardiac
arrhythmias and potential heart failure in these clients.
3. Which medication is considered the first-line treatment for a client experiencing alcohol
withdrawal?
A. Methadone
B. Disulfiram (Antabuse)
C. Lorazepam (Ativan)
D. Fluoxetine (Prozac)
Correct Answer: C
Expert Explanation: Benzodiazepines like Lorazepam are used to stabilize vital signs and
prevent seizures during alcohol withdrawal. They act by enhancing the effects of GABA in
the central nervous system. Using a standardized tool like the CIWA-Ar scale helps
determine the appropriate dosage for the client.
4. A nurse is assessing a client with Antisocial Personality Disorder. Which behavior should
the nurse expect?
A. Lack of remorse and disregard for the rights of others.
, B. Fear of being alone and low self-esteem.
C. Excessive emotionality and attention-seeking.
D. Extreme social inhibition due to fear of rejection.
Correct Answer: A
Expert Explanation: Antisocial Personality Disorder is characterized by a pattern of
manipulation and violation of others’ rights without guilt. These clients often have a history
of legal issues or conduct disorder during childhood. The nurse must set firm, clear limits
to manage manipulative behaviors effectively.
5. A client is experiencing symptoms of Wernicke-Korsakoff syndrome. What is the primary
cause of this condition?
A. Vitamin C deficiency
B. Thiamine (Vitamin B1) deficiency
C. Iron deficiency
D. Calcium deficiency
Correct Answer: B
Expert Explanation: Wernicke-Korsakoff syndrome is a neurological disorder often
associated with chronic alcohol use disorder. It is caused by a severe deficiency of thiamine,
which is essential for brain function. Early intervention with thiamine replacement is
necessary to prevent permanent brain damage or psychosis.
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder who is using splitting.
Which action should the nurse take?
A. Maintain consistent boundaries and communicate with the treatment team.
B. Allow the client to choose their primary nurse daily.
C. Ignore the behavior to avoid reinforcing it.
D. Provide the client with extra attention to build rapport.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad. Consistency among the staff is crucial to prevent the client from
playing staff members against each other. Clear communication within the treatment team
ensures that everyone follows the same care plan and maintains professional boundaries.
2. A client with Anorexia Nervosa is admitted to the unit. Which of the following physical
findings is the nurse’s priority?
A. Heart rate of 38 beats per minute.
B. Report of amenorrhea for six months.
C. Presence of lanugo on the back and arms.
,D. Dry, flaky skin and brittle nails.
Correct Answer: A
Expert Explanation: A heart rate of 38 bpm indicates severe bradycardia, which is a
medical emergency. Physiological stability must be addressed before psychological issues
according to the ABCs and Maslow’s hierarchy. The nurse must monitor for cardiac
arrhythmias and potential heart failure in these clients.
3. Which medication is considered the first-line treatment for a client experiencing alcohol
withdrawal?
A. Methadone
B. Disulfiram (Antabuse)
C. Lorazepam (Ativan)
D. Fluoxetine (Prozac)
Correct Answer: C
Expert Explanation: Benzodiazepines like Lorazepam are used to stabilize vital signs and
prevent seizures during alcohol withdrawal. They act by enhancing the effects of GABA in
the central nervous system. Using a standardized tool like the CIWA-Ar scale helps
determine the appropriate dosage for the client.
4. A nurse is assessing a client with Antisocial Personality Disorder. Which behavior should
the nurse expect?
A. Lack of remorse and disregard for the rights of others.
, B. Fear of being alone and low self-esteem.
C. Excessive emotionality and attention-seeking.
D. Extreme social inhibition due to fear of rejection.
Correct Answer: A
Expert Explanation: Antisocial Personality Disorder is characterized by a pattern of
manipulation and violation of others’ rights without guilt. These clients often have a history
of legal issues or conduct disorder during childhood. The nurse must set firm, clear limits
to manage manipulative behaviors effectively.
5. A client is experiencing symptoms of Wernicke-Korsakoff syndrome. What is the primary
cause of this condition?
A. Vitamin C deficiency
B. Thiamine (Vitamin B1) deficiency
C. Iron deficiency
D. Calcium deficiency
Correct Answer: B
Expert Explanation: Wernicke-Korsakoff syndrome is a neurological disorder often
associated with chronic alcohol use disorder. It is caused by a severe deficiency of thiamine,
which is essential for brain function. Early intervention with thiamine replacement is
necessary to prevent permanent brain damage or psychosis.
