NSG 322/NSG322 Exam 4 V1 |
Behavioral Health Nursing Q&A
with Rationale | Grand Canyon
University
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
when talking about the staff. Which action should the nurse take?
A. Confront the client about their behavior immediately.
B. Allow the client to choose which nurse they prefer for the shift.
C. Hold a staff meeting to ensure consistency in the treatment plan.
D. Ignore the behavior to avoid reinforcing it.
Correct Answer: C
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where the client views individuals as all good or all bad. Consistency among the
healthcare team is vital to prevent the client from playing staff members against each other.
By maintaining a unified approach, the nurse helps create a stable environment that
supports the client’s treatment goals.
2. Which of the following is a characteristic finding in a client diagnosed with Anorexia
Nervosa?
A. Tachycardia
,B. Lanugo
C. Hypertension
D. Hyperkalemia
Correct Answer: B
Expert Explanation: Lanugo is the growth of fine, downy hair on the body as a
physiological response to extreme malnutrition and loss of body fat. It serves as an attempt
by the body to insulate itself and maintain heat in the absence of subcutaneous fat. Other
signs often include bradycardia and hypotension rather than tachycardia and hypertension.
3. A client is prescribed Donepezil (Aricept) for Alzheimer’s disease. What information should
the nurse include in the teaching?
A. The medication will cure the disease over time.
B. Take the medication on an empty stomach for better absorption.
C. Common side effects include nausea, vomiting, and diarrhea.
D. This drug is only used for the late stages of Alzheimer’s.
Correct Answer: C
Expert Explanation: Donepezil is a cholinesterase inhibitor that works by increasing
levels of acetylcholine in the brain. Gastrointestinal side effects like nausea and diarrhea
are the most frequent adverse reactions reported by patients. The nurse should explain
,that while it helps manage symptoms, it does not cure the underlying neurodegenerative
process.
4. A school-aged child with ADHD is prescribed Methylphenidate. What is a priority nursing
assessment regarding this medication?
A. Assessment of height and weight.
B. Monitoring for increased appetite.
C. Assessing for signs of excessive sleepiness.
D. Checking for hearing loss.
Correct Answer: A
Expert Explanation: Methylphenidate is a stimulant medication commonly used to treat
ADHD, but it carries a risk of appetite suppression. This can lead to growth delays or
weight loss in pediatric patients, requiring regular monitoring of growth charts. Nurses
must educate parents to provide high-calorie meals and track the child’s development
closely during therapy.
5. A nurse is assessing an adolescent with Conduct Disorder. Which behavior is the nurse
most likely to observe?
A. Extreme shyness in social situations.
B. Excessive guilt after breaking a rule.
C. Difficulty leaving home to go to school.
, D. Physical aggression and violation of others’ rights.
Correct Answer: D
Expert Explanation: Conduct Disorder is characterized by a persistent pattern of behavior
that violates the basic rights of others or major societal norms. Common manifestations
include bullying, physical fights, and cruelty to animals or people. Unlike Oppositional
Defiant Disorder, Conduct Disorder involves more severe aggression and a lack of remorse
for harmful actions.
6. An elderly client is experiencing sudden confusion, fluctuating levels of consciousness, and
visual hallucinations. The nurse suspects:
A. Alzheimer’s disease
B. Vascular Dementia
C. Depression
D. Delirium
Correct Answer: D
Expert Explanation: Delirium is characterized by an acute onset of confusion and
fluctuating consciousness, often caused by an underlying medical condition like a UTI.
Alzheimer’s and other dementias typically involve a slow, progressive decline in cognition
over years. Visual hallucinations are also more commonly associated with the acute state of
delirium.
Behavioral Health Nursing Q&A
with Rationale | Grand Canyon
University
1. A nurse is caring for a client with Borderline Personality Disorder who is using ‘splitting’
when talking about the staff. Which action should the nurse take?
A. Confront the client about their behavior immediately.
B. Allow the client to choose which nurse they prefer for the shift.
C. Hold a staff meeting to ensure consistency in the treatment plan.
D. Ignore the behavior to avoid reinforcing it.
Correct Answer: C
Expert Explanation: Splitting is a common defense mechanism in Borderline Personality
Disorder where the client views individuals as all good or all bad. Consistency among the
healthcare team is vital to prevent the client from playing staff members against each other.
By maintaining a unified approach, the nurse helps create a stable environment that
supports the client’s treatment goals.
2. Which of the following is a characteristic finding in a client diagnosed with Anorexia
Nervosa?
A. Tachycardia
,B. Lanugo
C. Hypertension
D. Hyperkalemia
Correct Answer: B
Expert Explanation: Lanugo is the growth of fine, downy hair on the body as a
physiological response to extreme malnutrition and loss of body fat. It serves as an attempt
by the body to insulate itself and maintain heat in the absence of subcutaneous fat. Other
signs often include bradycardia and hypotension rather than tachycardia and hypertension.
3. A client is prescribed Donepezil (Aricept) for Alzheimer’s disease. What information should
the nurse include in the teaching?
A. The medication will cure the disease over time.
B. Take the medication on an empty stomach for better absorption.
C. Common side effects include nausea, vomiting, and diarrhea.
D. This drug is only used for the late stages of Alzheimer’s.
Correct Answer: C
Expert Explanation: Donepezil is a cholinesterase inhibitor that works by increasing
levels of acetylcholine in the brain. Gastrointestinal side effects like nausea and diarrhea
are the most frequent adverse reactions reported by patients. The nurse should explain
,that while it helps manage symptoms, it does not cure the underlying neurodegenerative
process.
4. A school-aged child with ADHD is prescribed Methylphenidate. What is a priority nursing
assessment regarding this medication?
A. Assessment of height and weight.
B. Monitoring for increased appetite.
C. Assessing for signs of excessive sleepiness.
D. Checking for hearing loss.
Correct Answer: A
Expert Explanation: Methylphenidate is a stimulant medication commonly used to treat
ADHD, but it carries a risk of appetite suppression. This can lead to growth delays or
weight loss in pediatric patients, requiring regular monitoring of growth charts. Nurses
must educate parents to provide high-calorie meals and track the child’s development
closely during therapy.
5. A nurse is assessing an adolescent with Conduct Disorder. Which behavior is the nurse
most likely to observe?
A. Extreme shyness in social situations.
B. Excessive guilt after breaking a rule.
C. Difficulty leaving home to go to school.
, D. Physical aggression and violation of others’ rights.
Correct Answer: D
Expert Explanation: Conduct Disorder is characterized by a persistent pattern of behavior
that violates the basic rights of others or major societal norms. Common manifestations
include bullying, physical fights, and cruelty to animals or people. Unlike Oppositional
Defiant Disorder, Conduct Disorder involves more severe aggression and a lack of remorse
for harmful actions.
6. An elderly client is experiencing sudden confusion, fluctuating levels of consciousness, and
visual hallucinations. The nurse suspects:
A. Alzheimer’s disease
B. Vascular Dementia
C. Depression
D. Delirium
Correct Answer: D
Expert Explanation: Delirium is characterized by an acute onset of confusion and
fluctuating consciousness, often caused by an underlying medical condition like a UTI.
Alzheimer’s and other dementias typically involve a slow, progressive decline in cognition
over years. Visual hallucinations are also more commonly associated with the acute state of
delirium.
