NSG 322/NSG322 Exam 4 V2 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the
following medications should the nurse expect to administer first to prevent seizures?
A. Disulfiram
B. Lorazepam
C. Fluoxetine
D. Methadone
Correct Answer: B
Expert Explanation: Lorazepam is a benzodiazepine used to stabilize vital signs and
prevent seizures during acute alcohol withdrawal. It acts on the GABA receptors to produce
a calming effect on the central nervous system. This medication is the gold standard for
managing the physical symptoms of withdrawal according to CIWA protocols.
2. A client with Alzheimer’s disease is caught wandering in the hallway at night. Which of the
following is the most appropriate nursing intervention?
A. Apply physical restraints to keep the client in bed.
B. Administer a high dose of a sedative to ensure sleep.
C. Gently lead the client back to their room and provide a nightlight.
D. Lock the client’s door from the outside.
Correct Answer: C
Expert Explanation: Wandering is a common symptom of neurocognitive disorders and
requires environmental management rather than physical or chemical restraints. Providing
a nightlight and a familiar environment helps reduce confusion and potential falls. Ensuring
the client’s safety while maintaining their dignity is a primary goal of behavioral health
nursing.
3. Which of the following findings is a priority for a nurse assessing a client with Anorexia
Nervosa?
A. Reporting a fear of gaining weight
B. Body weight 15% below ideal
C. Presence of lanugo on the back
D. Pulse rate of 38 beats per minute
Correct Answer: D
Expert Explanation: A heart rate of 38 beats per minute indicates severe bradycardia and
potential cardiovascular collapse, which is a life-threatening complication of anorexia.
,While weight loss and lanugo are diagnostic features, they are not as immediately
dangerous as hemodynamic instability. Hospitalization is usually required when the pulse
drops below 40 or the temperature is significantly low.
4. A client with Borderline Personality Disorder is using ‘splitting’ when talking to the staff.
How should the nurse best respond?
A. Agree with the client’s assessment of other staff members.
B. Avoid the client until their behavior improves.
C. Maintain consistent communication and limits with all staff members.
D. Assign a different nurse to the client every shift.
Correct Answer: C
Expert Explanation: Splitting is a defense mechanism where the client perceives
individuals as all good or all bad. To counteract this, the nursing team must remain unified
and consistent in their approach and rule enforcement. Open communication during shift
reports prevents the client from manipulating staff against one another.
5. A client is admitted for an opioid overdose. Which medication should the nurse have
available for immediate administration?
A. Varenicline
B. Naltrexone
C. Bupropion
D. Naloxone
Correct Answer: D
Expert Explanation: Naloxone is an opioid antagonist that quickly reverses respiratory
depression caused by opioid toxicity. It has a shorter half-life than most opioids, so the
nurse must monitor for the return of respiratory distress. Emergency administration of this
drug can be life-saving during an acute overdose event.
6. What is the primary difference between Delirium and Dementia?
A. Dementia is reversible, whereas delirium is not.
B. Delirium only affects elderly clients.
C. Delirium has a sudden onset, whereas dementia is progressive.
D. Dementia is always caused by an underlying medical infection.
Correct Answer: C
Expert Explanation: Delirium is characterized by an acute, rapid onset of confusion that is
often reversible once the underlying cause is treated. Dementia involves a slow,
irreversible decline in cognitive function over months or years. Understanding this
distinction is vital for determining the appropriate diagnostic tests and treatment plan.
, 7. A nurse is assessing a client with Bulimia Nervosa. Which physical finding is most
characteristic of this disorder?
A. Bradycardia and hypotension
B. High levels of physical energy and hyperactivity
C. Extreme weight loss and amenorrhea
D. Dental caries and parotid gland swelling
Correct Answer: D
Expert Explanation: Frequent vomiting in bulimia nervosa exposes teeth to stomach acid,
leading to enamel erosion and dental caries. The parotid glands often become swollen due
to the strain of repeated purging episodes. These physical markers help distinguish bulimia
from other eating disorders where purging may not be present.
8. A client is prescribed Disulfiram for alcohol use disorder. Which of the following should be
included in the patient education?
A. ‘You can drink small amounts of wine with dinner.’
B. ‘This medication will stop your cravings for alcohol.’
C. ‘Avoid all products containing alcohol, including mouthwash and hand sanitizer.’
D. ‘The medication takes effect within 30 minutes of drinking alcohol.’
Correct Answer: C
Expert Explanation: Disulfiram causes a severe adverse reaction when any amount of
alcohol is ingested, including those found in household products. The reaction includes
flushing, nausea, vomiting, and tachycardia. Clients must be warned to read all labels
carefully to avoid accidental exposure.
9. A nurse is caring for a client with Antisocial Personality Disorder. Which behavior is the
nurse most likely to observe?
A. Excessive emotionality and attention-seeking
B. Social inhibition and feelings of inadequacy
C. Submissive and clinging behavior
D. Lack of remorse and manipulation of others
Correct Answer: D
Expert Explanation: Antisocial Personality Disorder is characterized by a disregard for the
rights of others and a lack of empathy or remorse for harmful actions. These clients often
use charm and manipulation to achieve their personal goals. Setting firm, clear limits is the
most effective nursing strategy for managing these behaviors.
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the
following medications should the nurse expect to administer first to prevent seizures?
A. Disulfiram
B. Lorazepam
C. Fluoxetine
D. Methadone
Correct Answer: B
Expert Explanation: Lorazepam is a benzodiazepine used to stabilize vital signs and
prevent seizures during acute alcohol withdrawal. It acts on the GABA receptors to produce
a calming effect on the central nervous system. This medication is the gold standard for
managing the physical symptoms of withdrawal according to CIWA protocols.
2. A client with Alzheimer’s disease is caught wandering in the hallway at night. Which of the
following is the most appropriate nursing intervention?
A. Apply physical restraints to keep the client in bed.
B. Administer a high dose of a sedative to ensure sleep.
C. Gently lead the client back to their room and provide a nightlight.
D. Lock the client’s door from the outside.
Correct Answer: C
Expert Explanation: Wandering is a common symptom of neurocognitive disorders and
requires environmental management rather than physical or chemical restraints. Providing
a nightlight and a familiar environment helps reduce confusion and potential falls. Ensuring
the client’s safety while maintaining their dignity is a primary goal of behavioral health
nursing.
3. Which of the following findings is a priority for a nurse assessing a client with Anorexia
Nervosa?
A. Reporting a fear of gaining weight
B. Body weight 15% below ideal
C. Presence of lanugo on the back
D. Pulse rate of 38 beats per minute
Correct Answer: D
Expert Explanation: A heart rate of 38 beats per minute indicates severe bradycardia and
potential cardiovascular collapse, which is a life-threatening complication of anorexia.
,While weight loss and lanugo are diagnostic features, they are not as immediately
dangerous as hemodynamic instability. Hospitalization is usually required when the pulse
drops below 40 or the temperature is significantly low.
4. A client with Borderline Personality Disorder is using ‘splitting’ when talking to the staff.
How should the nurse best respond?
A. Agree with the client’s assessment of other staff members.
B. Avoid the client until their behavior improves.
C. Maintain consistent communication and limits with all staff members.
D. Assign a different nurse to the client every shift.
Correct Answer: C
Expert Explanation: Splitting is a defense mechanism where the client perceives
individuals as all good or all bad. To counteract this, the nursing team must remain unified
and consistent in their approach and rule enforcement. Open communication during shift
reports prevents the client from manipulating staff against one another.
5. A client is admitted for an opioid overdose. Which medication should the nurse have
available for immediate administration?
A. Varenicline
B. Naltrexone
C. Bupropion
D. Naloxone
Correct Answer: D
Expert Explanation: Naloxone is an opioid antagonist that quickly reverses respiratory
depression caused by opioid toxicity. It has a shorter half-life than most opioids, so the
nurse must monitor for the return of respiratory distress. Emergency administration of this
drug can be life-saving during an acute overdose event.
6. What is the primary difference between Delirium and Dementia?
A. Dementia is reversible, whereas delirium is not.
B. Delirium only affects elderly clients.
C. Delirium has a sudden onset, whereas dementia is progressive.
D. Dementia is always caused by an underlying medical infection.
Correct Answer: C
Expert Explanation: Delirium is characterized by an acute, rapid onset of confusion that is
often reversible once the underlying cause is treated. Dementia involves a slow,
irreversible decline in cognitive function over months or years. Understanding this
distinction is vital for determining the appropriate diagnostic tests and treatment plan.
, 7. A nurse is assessing a client with Bulimia Nervosa. Which physical finding is most
characteristic of this disorder?
A. Bradycardia and hypotension
B. High levels of physical energy and hyperactivity
C. Extreme weight loss and amenorrhea
D. Dental caries and parotid gland swelling
Correct Answer: D
Expert Explanation: Frequent vomiting in bulimia nervosa exposes teeth to stomach acid,
leading to enamel erosion and dental caries. The parotid glands often become swollen due
to the strain of repeated purging episodes. These physical markers help distinguish bulimia
from other eating disorders where purging may not be present.
8. A client is prescribed Disulfiram for alcohol use disorder. Which of the following should be
included in the patient education?
A. ‘You can drink small amounts of wine with dinner.’
B. ‘This medication will stop your cravings for alcohol.’
C. ‘Avoid all products containing alcohol, including mouthwash and hand sanitizer.’
D. ‘The medication takes effect within 30 minutes of drinking alcohol.’
Correct Answer: C
Expert Explanation: Disulfiram causes a severe adverse reaction when any amount of
alcohol is ingested, including those found in household products. The reaction includes
flushing, nausea, vomiting, and tachycardia. Clients must be warned to read all labels
carefully to avoid accidental exposure.
9. A nurse is caring for a client with Antisocial Personality Disorder. Which behavior is the
nurse most likely to observe?
A. Excessive emotionality and attention-seeking
B. Social inhibition and feelings of inadequacy
C. Submissive and clinging behavior
D. Lack of remorse and manipulation of others
Correct Answer: D
Expert Explanation: Antisocial Personality Disorder is characterized by a disregard for the
rights of others and a lack of empathy or remorse for harmful actions. These clients often
use charm and manipulation to achieve their personal goals. Setting firm, clear limits is the
most effective nursing strategy for managing these behaviors.
