NUR180/NUR 180 Exam 4 V2 | 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 experiencing alcohol withdrawal. Which of the following
clinical manifestations should the nurse identify as a sign of delirium tremens (DTs)?
A. Bradycardia and hypotension
B. Disorientation, tremors, and hallucinations
C. Hypersomnolence and clear sensorium
D. Increased appetite and weight gain
Correct Answer: B
Rationale: Delirium tremens is a severe form of alcohol withdrawal that typically occurs
48 to 96 hours after the last drink. Clinical manifestations include severe disorientation,
psychomotor agitation, and sensory hallucinations. The nurse must recognize these
symptoms immediately as they constitute a medical emergency requiring intensive
monitoring.
2. A client is prescribed disulfiram as part of their treatment for alcohol use disorder. Which
statement by the client indicates a need for further teaching?
A. I will avoid using alcohol-based hand sanitizers.
,B. I can have a glass of wine with dinner once a week.
C. I must read labels on cough syrups and mouthwashes.
D. I should wait at least 12 hours after my last drink before starting this medication.
Correct Answer: B
Rationale: Disulfiram works by causing a severe adverse reaction if even small amounts of
alcohol are ingested. Consuming wine would lead to nausea, vomiting, palpitations, and
potentially hypotension. The client must maintain total abstinence from alcohol to avoid
the disulfiram-alcohol reaction.
3. A nurse is assessing a client with Borderline Personality Disorder. Which defense
mechanism is commonly used by these clients where they see people as either all good or all
bad?
A. Projection
B. Sublimation
C. Splitting
D. Reaction Formation
Correct Answer: C
Rationale: Splitting is the primary defense mechanism utilized by individuals with
Borderline Personality Disorder to manage anxiety. It involves the inability to integrate
, positive and negative qualities of oneself or others into a cohesive image. This behavior
often leads to unstable relationships and conflict within the healthcare team.
4. An adolescent client is diagnosed with Conduct Disorder. Which behavior is the nurse most
likely to observe?
A. Repeatedly losing things and being easily distracted
B. Ritualistic hand washing and counting
C. Excessive shyness and fear of being judged
D. Physical cruelty to animals and violation of others’ rights
Correct Answer: D
Rationale: Conduct disorder is characterized by a persistent pattern of behavior that
violates the basic rights of others or major age-appropriate societal norms. Key indicators
include aggression toward people and animals, destruction of property, and deceitfulness.
Early intervention is crucial to prevent the progression to antisocial personality disorder in
adulthood.
5. A nurse is caring for an elderly client with Alzheimer’s disease who is frequently wandering
at night. Which intervention should the nurse prioritize?
A. Apply physical restraints during the night shift.
B. Administer high doses of sedatives before bedtime.
C. Place the client in a room near the nurses’ station.
Mental Health Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following
clinical manifestations should the nurse identify as a sign of delirium tremens (DTs)?
A. Bradycardia and hypotension
B. Disorientation, tremors, and hallucinations
C. Hypersomnolence and clear sensorium
D. Increased appetite and weight gain
Correct Answer: B
Rationale: Delirium tremens is a severe form of alcohol withdrawal that typically occurs
48 to 96 hours after the last drink. Clinical manifestations include severe disorientation,
psychomotor agitation, and sensory hallucinations. The nurse must recognize these
symptoms immediately as they constitute a medical emergency requiring intensive
monitoring.
2. A client is prescribed disulfiram as part of their treatment for alcohol use disorder. Which
statement by the client indicates a need for further teaching?
A. I will avoid using alcohol-based hand sanitizers.
,B. I can have a glass of wine with dinner once a week.
C. I must read labels on cough syrups and mouthwashes.
D. I should wait at least 12 hours after my last drink before starting this medication.
Correct Answer: B
Rationale: Disulfiram works by causing a severe adverse reaction if even small amounts of
alcohol are ingested. Consuming wine would lead to nausea, vomiting, palpitations, and
potentially hypotension. The client must maintain total abstinence from alcohol to avoid
the disulfiram-alcohol reaction.
3. A nurse is assessing a client with Borderline Personality Disorder. Which defense
mechanism is commonly used by these clients where they see people as either all good or all
bad?
A. Projection
B. Sublimation
C. Splitting
D. Reaction Formation
Correct Answer: C
Rationale: Splitting is the primary defense mechanism utilized by individuals with
Borderline Personality Disorder to manage anxiety. It involves the inability to integrate
, positive and negative qualities of oneself or others into a cohesive image. This behavior
often leads to unstable relationships and conflict within the healthcare team.
4. An adolescent client is diagnosed with Conduct Disorder. Which behavior is the nurse most
likely to observe?
A. Repeatedly losing things and being easily distracted
B. Ritualistic hand washing and counting
C. Excessive shyness and fear of being judged
D. Physical cruelty to animals and violation of others’ rights
Correct Answer: D
Rationale: Conduct disorder is characterized by a persistent pattern of behavior that
violates the basic rights of others or major age-appropriate societal norms. Key indicators
include aggression toward people and animals, destruction of property, and deceitfulness.
Early intervention is crucial to prevent the progression to antisocial personality disorder in
adulthood.
5. A nurse is caring for an elderly client with Alzheimer’s disease who is frequently wandering
at night. Which intervention should the nurse prioritize?
A. Apply physical restraints during the night shift.
B. Administer high doses of sedatives before bedtime.
C. Place the client in a room near the nurses’ station.
