NSG 322/NSG322 Final Exam V3 |
Behavioral Health Nursing Q&A
with Rationale | Grand Canyon
University
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations. Which is the
priority nursing intervention during the initial phase of treatment?
A. Tell the client that the voices are not real and they should ignore
them.
B. Ask the client what the voices are saying to assess for safety
risks.
C. Leave the client alone to provide a quiet environment for rest.
D. Provide a complex activity to distract the client from the
hallucinations.
Correct Answer: B
Expert Explanation: The nurse’s priority is to assess the content of the hallucinations to
determine if they are command hallucinations. If the voices are instructing the client to
harm themselves or others, immediate safety precautions must be implemented. This
assessment allows the nurse to understand the client’s internal experience while ensuring
the safety of the milieu.
2. A client is prescribed lithium carbonate for bipolar disorder. Which lab value should the
nurse monitor most closely to prevent toxicity?
A. Serum potassium levels
B. Prothrombin time (PT)
,C. Serum sodium levels
D. Serum calcium levels
Correct Answer: C
Expert Explanation: Lithium is a salt and is handled by the body in a manner similar to
sodium. When sodium levels are low, the kidneys retain lithium, which can lead to toxic
accumulations. The nurse must ensure the client maintains a steady intake of sodium and
fluid to prevent this imbalance.
3. A nurse is caring for a client with borderline personality disorder. Which behavior is most
characteristic of this diagnosis?
A. Submissive and clinging behavior related to an excessive need to be taken care of.
B. Patterns of unstable and intense interpersonal relationships.
C. Social inhibition and feelings of inadequacy.
D. A pervasive pattern of disregard for and violation of the rights of others.
Correct Answer: B
Expert Explanation: Borderline personality disorder is characterized by instability in
affect, identity, and relationships. Clients often experience ‘splitting,’ where they view
people as all good or all bad. This leads to intense and often chaotic interactions with staff
and peers in a healthcare setting.
4. A client is experiencing a panic attack. Which nursing intervention is most appropriate?
A. Ask the client to explain the reason for the panic.
, B. Encourage the client to join a group therapy session.
C. Stay with the client and use a calm, low-pitched voice.
D. Leave the room to give the client privacy until the attack passes.
Correct Answer: C
Expert Explanation: During a panic attack, the client’s level of anxiety prevents them from
processing complex information or learning new skills. Staying with the client provides a
sense of safety and security. Using a calm voice helps to lower the intensity of the client’s
autonomic nervous system response.
5. A nurse is reviewing the chart of a client with anorexia nervosa. Which physical finding is
commonly associated with this disorder?
A. Hypertension and tachycardia
B. Lanugo and bradycardia
C. Hyperthermia and oily skin
D. Increased muscle mass and high BMI
Correct Answer: B
Expert Explanation: Lanugo, which is fine, downy hair, grows on the body as a
physiological response to extreme weight loss and low body temperature. Bradycardia and
hypotension are also common as the body attempts to conserve energy. These findings
indicate severe malnutrition and a high risk for medical instability.
Behavioral Health Nursing Q&A
with Rationale | Grand Canyon
University
1. A client diagnosed with schizophrenia is experiencing auditory hallucinations. Which is the
priority nursing intervention during the initial phase of treatment?
A. Tell the client that the voices are not real and they should ignore
them.
B. Ask the client what the voices are saying to assess for safety
risks.
C. Leave the client alone to provide a quiet environment for rest.
D. Provide a complex activity to distract the client from the
hallucinations.
Correct Answer: B
Expert Explanation: The nurse’s priority is to assess the content of the hallucinations to
determine if they are command hallucinations. If the voices are instructing the client to
harm themselves or others, immediate safety precautions must be implemented. This
assessment allows the nurse to understand the client’s internal experience while ensuring
the safety of the milieu.
2. A client is prescribed lithium carbonate for bipolar disorder. Which lab value should the
nurse monitor most closely to prevent toxicity?
A. Serum potassium levels
B. Prothrombin time (PT)
,C. Serum sodium levels
D. Serum calcium levels
Correct Answer: C
Expert Explanation: Lithium is a salt and is handled by the body in a manner similar to
sodium. When sodium levels are low, the kidneys retain lithium, which can lead to toxic
accumulations. The nurse must ensure the client maintains a steady intake of sodium and
fluid to prevent this imbalance.
3. A nurse is caring for a client with borderline personality disorder. Which behavior is most
characteristic of this diagnosis?
A. Submissive and clinging behavior related to an excessive need to be taken care of.
B. Patterns of unstable and intense interpersonal relationships.
C. Social inhibition and feelings of inadequacy.
D. A pervasive pattern of disregard for and violation of the rights of others.
Correct Answer: B
Expert Explanation: Borderline personality disorder is characterized by instability in
affect, identity, and relationships. Clients often experience ‘splitting,’ where they view
people as all good or all bad. This leads to intense and often chaotic interactions with staff
and peers in a healthcare setting.
4. A client is experiencing a panic attack. Which nursing intervention is most appropriate?
A. Ask the client to explain the reason for the panic.
, B. Encourage the client to join a group therapy session.
C. Stay with the client and use a calm, low-pitched voice.
D. Leave the room to give the client privacy until the attack passes.
Correct Answer: C
Expert Explanation: During a panic attack, the client’s level of anxiety prevents them from
processing complex information or learning new skills. Staying with the client provides a
sense of safety and security. Using a calm voice helps to lower the intensity of the client’s
autonomic nervous system response.
5. A nurse is reviewing the chart of a client with anorexia nervosa. Which physical finding is
commonly associated with this disorder?
A. Hypertension and tachycardia
B. Lanugo and bradycardia
C. Hyperthermia and oily skin
D. Increased muscle mass and high BMI
Correct Answer: B
Expert Explanation: Lanugo, which is fine, downy hair, grows on the body as a
physiological response to extreme weight loss and low body temperature. Bradycardia and
hypotension are also common as the body attempts to conserve energy. These findings
indicate severe malnutrition and a high risk for medical instability.
