PRN 1562/PRN1562 Exam 3 V3 | 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 frequently using
‘splitting’ when interacting with staff. What is the most appropriate nursing intervention?
A. Hold a staff meeting to ensure all team members provide a consistent response.
B. Allow the client to choose which nurse they prefer to work with.
C. Explain to the client how their behavior is affecting the staff’s feelings.
D. Isolate the client until they can interact more appropriately with the team.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client perceives people as
all good or all bad, which can cause conflict among staff. Consistency in the treatment
team’s approach is essential to minimize the effectiveness of this behavior and maintain the
therapeutic environment. By holding a staff meeting, the team can align their
communication and boundaries, preventing the client from manipulating the staff members
against each other.
2. A client is admitted to the detoxification unit for alcohol withdrawal. Which of the
following symptoms should the nurse expect to see within the first 6 to 12 hours?
A. Visual hallucinations and seizures
,B. Extreme lethargy and bradycardia
C. Tremors, tachycardia, and anxiety
D. Deep sleep and increased appetite
Correct Answer: C
Expert Explanation: Early symptoms of alcohol withdrawal typically appear within 6 to
12 hours after the last drink and include autonomic hyperactivity such as tremors and
tachycardia. Anxiety and irritability are also common psychological manifestations during
this initial phase of withdrawal. Recognizing these early signs is crucial for the nurse to
initiate the prescribed detoxification protocol and prevent progression to more severe
symptoms like delirium tremens.
3. A nurse is providing education to a client prescribed Disulfiram (Antabuse). Which
statement by the client indicates an understanding of the teaching?
A. ‘I should only avoid drinking alcohol while I am taking this pill.’
B. ‘I can stop taking the medication whenever I feel my cravings are gone.’
C. ‘If I drink alcohol, I will feel a pleasant euphoric sensation.’
D. ‘I need to check labels for alcohol in products like mouthwash and cough syrup.’
Correct Answer: D
Expert Explanation: Disulfiram works by causing a severe adverse reaction when any
form of alcohol is ingested, including hidden sources in household products. The client
,must be educated to avoid not just alcoholic beverages, but also mouthwash, aftershave,
and certain food flavorings that contain ethanol. This education is vital because the
reaction can be life-threatening and may occur even several days after the last dose of
Disulfiram is taken.
4. An adolescent client with Anorexia Nervosa has a nursing diagnosis of Imbalanced
Nutrition: Less than Body Requirements. What is the primary goal of the initial phase of
treatment?
A. Restoring the client to a weight that is safe and physically stable.
B. Encouraging the client to exercise to improve their cardiovascular health.
C. Identifying the underlying psychological cause of the eating disorder.
D. Teaching the client how to cook healthy meals for their family.
Correct Answer: A
Expert Explanation: In the initial treatment phase for Anorexia Nervosa, physical stability
and weight restoration are the highest priorities to prevent life-threatening complications.
Psychological exploration is secondary until the client’s cognitive function improves with
better nutritional status. The nurse must monitor the client closely for refeeding syndrome
as caloric intake is gradually increased to reach the target weight.
5. A client with Antisocial Personality Disorder is being treated on an inpatient unit. Which
behavior is most characteristic of this diagnosis?
A. Excessive emotionality and attention-seeking behavior.
, B. Preoccupation with orderliness, perfectionism, and control.
C. Social withdrawal and intense fear of being criticized.
D. Disregard for the rights of others and lack of remorse for actions.
Correct Answer: D
Expert Explanation: Antisocial Personality Disorder is characterized by a pattern of
behavior that violates the rights of others and a lack of empathy or guilt. These individuals
often engage in deceitful, impulsive, and sometimes illegal activities without regard for the
consequences. The nursing approach must focus on setting firm, consistent limits on
behavior and holding the client accountable for their actions.
6. The nurse is assessing a client with Obsessive-Compulsive Disorder (OCD) who performs
hand-washing rituals. Why does the client perform these rituals?
A. To gain attention from the nursing staff and family.
B. To exert control over the environment and other people.
C. To improve their personal hygiene and physical health.
D. To relieve the intense anxiety caused by intrusive thoughts.
Correct Answer: D
Expert Explanation: Compulsions in OCD are repetitive behaviors that an individual feels
driven to perform in response to an obsession or according to rigid rules. These rituals
serve as a temporary mechanism to reduce the overwhelming anxiety generated by
of Mental Health Nursing Q&A with
Rationale | Rasmussen University
1. A nurse is caring for a client with Borderline Personality Disorder who is frequently using
‘splitting’ when interacting with staff. What is the most appropriate nursing intervention?
A. Hold a staff meeting to ensure all team members provide a consistent response.
B. Allow the client to choose which nurse they prefer to work with.
C. Explain to the client how their behavior is affecting the staff’s feelings.
D. Isolate the client until they can interact more appropriately with the team.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client perceives people as
all good or all bad, which can cause conflict among staff. Consistency in the treatment
team’s approach is essential to minimize the effectiveness of this behavior and maintain the
therapeutic environment. By holding a staff meeting, the team can align their
communication and boundaries, preventing the client from manipulating the staff members
against each other.
2. A client is admitted to the detoxification unit for alcohol withdrawal. Which of the
following symptoms should the nurse expect to see within the first 6 to 12 hours?
A. Visual hallucinations and seizures
,B. Extreme lethargy and bradycardia
C. Tremors, tachycardia, and anxiety
D. Deep sleep and increased appetite
Correct Answer: C
Expert Explanation: Early symptoms of alcohol withdrawal typically appear within 6 to
12 hours after the last drink and include autonomic hyperactivity such as tremors and
tachycardia. Anxiety and irritability are also common psychological manifestations during
this initial phase of withdrawal. Recognizing these early signs is crucial for the nurse to
initiate the prescribed detoxification protocol and prevent progression to more severe
symptoms like delirium tremens.
3. A nurse is providing education to a client prescribed Disulfiram (Antabuse). Which
statement by the client indicates an understanding of the teaching?
A. ‘I should only avoid drinking alcohol while I am taking this pill.’
B. ‘I can stop taking the medication whenever I feel my cravings are gone.’
C. ‘If I drink alcohol, I will feel a pleasant euphoric sensation.’
D. ‘I need to check labels for alcohol in products like mouthwash and cough syrup.’
Correct Answer: D
Expert Explanation: Disulfiram works by causing a severe adverse reaction when any
form of alcohol is ingested, including hidden sources in household products. The client
,must be educated to avoid not just alcoholic beverages, but also mouthwash, aftershave,
and certain food flavorings that contain ethanol. This education is vital because the
reaction can be life-threatening and may occur even several days after the last dose of
Disulfiram is taken.
4. An adolescent client with Anorexia Nervosa has a nursing diagnosis of Imbalanced
Nutrition: Less than Body Requirements. What is the primary goal of the initial phase of
treatment?
A. Restoring the client to a weight that is safe and physically stable.
B. Encouraging the client to exercise to improve their cardiovascular health.
C. Identifying the underlying psychological cause of the eating disorder.
D. Teaching the client how to cook healthy meals for their family.
Correct Answer: A
Expert Explanation: In the initial treatment phase for Anorexia Nervosa, physical stability
and weight restoration are the highest priorities to prevent life-threatening complications.
Psychological exploration is secondary until the client’s cognitive function improves with
better nutritional status. The nurse must monitor the client closely for refeeding syndrome
as caloric intake is gradually increased to reach the target weight.
5. A client with Antisocial Personality Disorder is being treated on an inpatient unit. Which
behavior is most characteristic of this diagnosis?
A. Excessive emotionality and attention-seeking behavior.
, B. Preoccupation with orderliness, perfectionism, and control.
C. Social withdrawal and intense fear of being criticized.
D. Disregard for the rights of others and lack of remorse for actions.
Correct Answer: D
Expert Explanation: Antisocial Personality Disorder is characterized by a pattern of
behavior that violates the rights of others and a lack of empathy or guilt. These individuals
often engage in deceitful, impulsive, and sometimes illegal activities without regard for the
consequences. The nursing approach must focus on setting firm, consistent limits on
behavior and holding the client accountable for their actions.
6. The nurse is assessing a client with Obsessive-Compulsive Disorder (OCD) who performs
hand-washing rituals. Why does the client perform these rituals?
A. To gain attention from the nursing staff and family.
B. To exert control over the environment and other people.
C. To improve their personal hygiene and physical health.
D. To relieve the intense anxiety caused by intrusive thoughts.
Correct Answer: D
Expert Explanation: Compulsions in OCD are repetitive behaviors that an individual feels
driven to perform in response to an obsession or according to rigid rules. These rituals
serve as a temporary mechanism to reduce the overwhelming anxiety generated by
