NUR180/NUR 180 Exam 4 V3 | Concepts of
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is attempting to pit
the day shift staff against the night shift staff. Which term describes this behavior?
A. Splitting
B. Projection
C. Rationalization
D. Reaction Formation
Correct Answer: A
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as all good or all bad. This behavior often leads to
conflict and inconsistency among staff members who are trying to provide care. The nurse
must recognize this pattern to ensure a unified treatment approach is maintained.
2. Which physical assessment finding is most characteristic of a client with a long-term
diagnosis of Anorexia Nervosa?
A. Lanugo
B. Tachycardia
,C. Hypertension
D. Warm, flushed skin
Correct Answer: A
Rationale: Lanugo is the growth of fine, downy hair on the body as a physiological
response to extreme weight loss and cold intolerance. Clients with anorexia often exhibit
bradycardia and hypotension rather than tachycardia and hypertension due to metabolic
slowing. Recognizing these physical indicators is vital for the nurse to assess the severity of
malnutrition.
3. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering to prevent seizures and manage tremors during the acute phase?
A. Disulfiram
B. Methadone
C. Naltrexone
D. Chlordiazepoxide
Correct Answer: D
Rationale: Benzodiazepines like chlordiazepoxide are the gold standard for managing
acute alcohol withdrawal symptoms. These medications help stabilize vital signs and
reduce the risk of withdrawal-related seizures or delirium tremens. Other medications like
Disulfiram are used for long-term sobriety maintenance rather than acute detox.
, 4. A child is diagnosed with Conduct Disorder. Which behavior should the nurse expect to
observe during the assessment?
A. Difficulty paying attention in class
B. Difficulty maintaining eye contact
C. Excessive hand washing
D. Physical aggression toward animals and others
Correct Answer: D
Rationale: Conduct Disorder is characterized by a persistent pattern of violating the basic
rights of others and major age-appropriate societal norms. This includes aggression,
destruction of property, and deceitfulness or theft. Unlike ADHD which focuses on
attention, Conduct Disorder involves a more severe lack of empathy and frequent rule-
breaking.
5. An elderly client with Alzheimer’s disease frequently wanders the halls at night. Which
intervention should the nurse implement first?
A. Apply a vest restraint while the client is in bed
B. Assess the client for unmet needs such as hunger or toileting
C. Place the mattress on the floor to prevent falls
D. Administer a PRN sedative
Correct Answer: B
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client with Borderline Personality Disorder who is attempting to pit
the day shift staff against the night shift staff. Which term describes this behavior?
A. Splitting
B. Projection
C. Rationalization
D. Reaction Formation
Correct Answer: A
Rationale: Splitting is a common defense mechanism in Borderline Personality Disorder
where the client views individuals as all good or all bad. This behavior often leads to
conflict and inconsistency among staff members who are trying to provide care. The nurse
must recognize this pattern to ensure a unified treatment approach is maintained.
2. Which physical assessment finding is most characteristic of a client with a long-term
diagnosis of Anorexia Nervosa?
A. Lanugo
B. Tachycardia
,C. Hypertension
D. Warm, flushed skin
Correct Answer: A
Rationale: Lanugo is the growth of fine, downy hair on the body as a physiological
response to extreme weight loss and cold intolerance. Clients with anorexia often exhibit
bradycardia and hypotension rather than tachycardia and hypertension due to metabolic
slowing. Recognizing these physical indicators is vital for the nurse to assess the severity of
malnutrition.
3. A client is admitted for alcohol detoxification. Which medication should the nurse
anticipate administering to prevent seizures and manage tremors during the acute phase?
A. Disulfiram
B. Methadone
C. Naltrexone
D. Chlordiazepoxide
Correct Answer: D
Rationale: Benzodiazepines like chlordiazepoxide are the gold standard for managing
acute alcohol withdrawal symptoms. These medications help stabilize vital signs and
reduce the risk of withdrawal-related seizures or delirium tremens. Other medications like
Disulfiram are used for long-term sobriety maintenance rather than acute detox.
, 4. A child is diagnosed with Conduct Disorder. Which behavior should the nurse expect to
observe during the assessment?
A. Difficulty paying attention in class
B. Difficulty maintaining eye contact
C. Excessive hand washing
D. Physical aggression toward animals and others
Correct Answer: D
Rationale: Conduct Disorder is characterized by a persistent pattern of violating the basic
rights of others and major age-appropriate societal norms. This includes aggression,
destruction of property, and deceitfulness or theft. Unlike ADHD which focuses on
attention, Conduct Disorder involves a more severe lack of empathy and frequent rule-
breaking.
5. An elderly client with Alzheimer’s disease frequently wanders the halls at night. Which
intervention should the nurse implement first?
A. Apply a vest restraint while the client is in bed
B. Assess the client for unmet needs such as hunger or toileting
C. Place the mattress on the floor to prevent falls
D. Administer a PRN sedative
Correct Answer: B
