PNR 200/PNR200 Exam 4 V1 | Mental
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who is
currently ‘splitting’ the staff. Which nursing intervention is most appropriate?
A. Hold a staff meeting to ensure a consistent approach to the client’s care.
B. Allow the client to choose which nurse will provide care for the shift.
C. Ignore the behavior to avoid reinforcing the client’s manipulative tactics.
D. Confront the client immediately about the inaccuracy of their statements.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad, which can cause significant conflict among the healthcare team.
Holding a staff meeting ensures that all members of the team are providing consistent
boundaries and responses to the client’s behavior. This unified approach prevents the
client from playing one staff member against another and promotes a stable therapeutic
environment.
2. A client is admitted to the psychiatric unit with a diagnosis of Anorexia Nervosa. Which of
the following is the priority nursing intervention?
A. Discussing the client’s distorted body image.
,B. Implementing a structured meal plan and monitoring intake.
C. Encouraging the client to express feelings of anxiety.
D. Teaching the client healthy coping mechanisms for stress.
Correct Answer: B
Expert Explanation: While addressing psychological issues is important, the immediate
priority for a client with anorexia nervosa is physiological stabilization and nutritional
restoration. Monitoring intake and output ensures the client is receiving adequate calories
and prevents complications like refeeding syndrome. Safety and physical health must
always be addressed before deep psychotherapy can be effective in this population.
3. The nurse is assessing a client for potential alcohol withdrawal. Which early symptom
should the nurse expect to find?
A. Bradycardia
B. Hypotension
C. Coarse tremors of the hands
D. Increased appetite
Correct Answer: C
Expert Explanation: Early symptoms of alcohol withdrawal typically begin 6 to 8 hours
after the last drink and include coarse tremors, tachycardia, and hypertension. These signs
indicate autonomic hyperactivity as the central nervous system rebounds from the sedative
,effects of alcohol. Recognizing these early signs is crucial for the timely administration of
benzodiazepines to prevent progression to seizures or delirium tremens.
4. A nurse is educating a client about a new prescription for Lithium Carbonate. Which
statement by the client indicates a need for further teaching?
A. ‘I will make sure to drink plenty of water every day.’
B. ‘I should limit my salt intake to help the medication work better.’
C. ‘I need to have my blood levels checked regularly.’
D. ‘I will call my doctor if I experience persistent diarrhea or vomiting.’
Correct Answer: B
Expert Explanation: Clients taking lithium must maintain a consistent intake of dietary
sodium because lithium is a salt. If sodium intake is restricted, the kidneys reabsorb lithium
instead of sodium, which can lead to toxic levels in the blood. The client should be taught to
maintain normal salt and fluid intake to ensure medication safety.
5. A client with Alzheimer’s disease frequently wanders the hallways at night. Which
intervention should the nurse implement first?
A. Administer a prescribed sedative to help the client sleep.
B. Place the client in soft wrist restraints to ensure safety.
C. Move the client to a room closer to the nurses’ station.
D. Ensure the client’s environment is well-lit and free of clutter.
, Correct Answer: C
Expert Explanation: Moving the client closer to the nurses’ station allows for more
frequent observation and increases safety without the use of restrictive measures.
Frequent monitoring is the primary goal for clients who wander to prevent falls and
elopement. Restraints are a last resort and often increase agitation in clients with
dementia.
6. Which personality disorder is characterized by a pervasive pattern of grandiosity, a need
for admiration, and a lack of empathy?
A. Antisocial Personality Disorder
B. Schizoid Personality Disorder
C. Histrionic Personality Disorder
D. Narcissistic Personality Disorder
Correct Answer: D
Expert Explanation: Narcissistic Personality Disorder involves a sense of self-importance
and a preoccupation with fantasies of unlimited success or power. These individuals often
exploit others for their own gain and lack the ability to recognize the feelings of those
around them. Treatment focuses on slowly building empathy and addressing the
underlying fragile self-esteem.
Health Nursing Q&A with Rationale | Fortis
College
1. A nurse is caring for a client diagnosed with Borderline Personality Disorder who is
currently ‘splitting’ the staff. Which nursing intervention is most appropriate?
A. Hold a staff meeting to ensure a consistent approach to the client’s care.
B. Allow the client to choose which nurse will provide care for the shift.
C. Ignore the behavior to avoid reinforcing the client’s manipulative tactics.
D. Confront the client immediately about the inaccuracy of their statements.
Correct Answer: A
Expert Explanation: Splitting is a defense mechanism where the client views individuals
as all good or all bad, which can cause significant conflict among the healthcare team.
Holding a staff meeting ensures that all members of the team are providing consistent
boundaries and responses to the client’s behavior. This unified approach prevents the
client from playing one staff member against another and promotes a stable therapeutic
environment.
2. A client is admitted to the psychiatric unit with a diagnosis of Anorexia Nervosa. Which of
the following is the priority nursing intervention?
A. Discussing the client’s distorted body image.
,B. Implementing a structured meal plan and monitoring intake.
C. Encouraging the client to express feelings of anxiety.
D. Teaching the client healthy coping mechanisms for stress.
Correct Answer: B
Expert Explanation: While addressing psychological issues is important, the immediate
priority for a client with anorexia nervosa is physiological stabilization and nutritional
restoration. Monitoring intake and output ensures the client is receiving adequate calories
and prevents complications like refeeding syndrome. Safety and physical health must
always be addressed before deep psychotherapy can be effective in this population.
3. The nurse is assessing a client for potential alcohol withdrawal. Which early symptom
should the nurse expect to find?
A. Bradycardia
B. Hypotension
C. Coarse tremors of the hands
D. Increased appetite
Correct Answer: C
Expert Explanation: Early symptoms of alcohol withdrawal typically begin 6 to 8 hours
after the last drink and include coarse tremors, tachycardia, and hypertension. These signs
indicate autonomic hyperactivity as the central nervous system rebounds from the sedative
,effects of alcohol. Recognizing these early signs is crucial for the timely administration of
benzodiazepines to prevent progression to seizures or delirium tremens.
4. A nurse is educating a client about a new prescription for Lithium Carbonate. Which
statement by the client indicates a need for further teaching?
A. ‘I will make sure to drink plenty of water every day.’
B. ‘I should limit my salt intake to help the medication work better.’
C. ‘I need to have my blood levels checked regularly.’
D. ‘I will call my doctor if I experience persistent diarrhea or vomiting.’
Correct Answer: B
Expert Explanation: Clients taking lithium must maintain a consistent intake of dietary
sodium because lithium is a salt. If sodium intake is restricted, the kidneys reabsorb lithium
instead of sodium, which can lead to toxic levels in the blood. The client should be taught to
maintain normal salt and fluid intake to ensure medication safety.
5. A client with Alzheimer’s disease frequently wanders the hallways at night. Which
intervention should the nurse implement first?
A. Administer a prescribed sedative to help the client sleep.
B. Place the client in soft wrist restraints to ensure safety.
C. Move the client to a room closer to the nurses’ station.
D. Ensure the client’s environment is well-lit and free of clutter.
, Correct Answer: C
Expert Explanation: Moving the client closer to the nurses’ station allows for more
frequent observation and increases safety without the use of restrictive measures.
Frequent monitoring is the primary goal for clients who wander to prevent falls and
elopement. Restraints are a last resort and often increase agitation in clients with
dementia.
6. Which personality disorder is characterized by a pervasive pattern of grandiosity, a need
for admiration, and a lack of empathy?
A. Antisocial Personality Disorder
B. Schizoid Personality Disorder
C. Histrionic Personality Disorder
D. Narcissistic Personality Disorder
Correct Answer: D
Expert Explanation: Narcissistic Personality Disorder involves a sense of self-importance
and a preoccupation with fantasies of unlimited success or power. These individuals often
exploit others for their own gain and lack the ability to recognize the feelings of those
around them. Treatment focuses on slowly building empathy and addressing the
underlying fragile self-esteem.
