NR-326 Mental Health Nursing - Set 4 - Part 1

Correct Answer: Give the thiamine before or with the glucose

Thiamine is the cofactor the body needs to burn glucose. Loading a depleted client with glucose first consumes the last of that thiamine and can tip him into Wernicke encephalopathy, so thiamine goes in first. Option a is incorrect because glucose given ahead of thiamine is the classic trigger for acute Wernicke encephalopathy in a depleted drinker. The sugar is still needed, but the order of administration decides the outcome. Option b is incorrect because both medications are already ordered and delay serves no one. Symptomatic hypoglycemia needs prompt correction, and holding treatment while waiting for a callback risks seizure and further neurologic harm. Option d is incorrect because oral intake is unreliable in this population and absorption from the gut is poor. Waiting for a meal wastes the narrow window in which replacement still protects the brain.

Correct Answer: Detoxification is the first step, not the treatment

Detoxification stabilizes the body and relieves symptoms, but recurrence rates after it alone are very high. Its real purpose is to hand the client over to rehabilitation, outpatient care, and continuing support. Option b is incorrect because clearing the substance changes nothing about craving, conditioned cues, or the life circumstances that surround use. A person discharged straight home from detoxification usually returns to using within weeks. Option c is incorrect because rehabilitation is offered from the start, not held back as a penalty for earlier attempts. Framing it that way would discourage exactly the clients who most need to enroll. Option d is incorrect because the two work together rather than in sequence. Medication for alcohol or opioid use disorder is often started as detoxification ends and continues alongside counseling and group work.

Correct Answer: An unstable self-image with chronic feelings of emptiness

Identity disturbance and chronic emptiness sit alongside unstable relationships in borderline personality disorder. The client describes a hollow, numb state and a self-image that shifts with whoever is nearby. Option a is incorrect because a settled sense of self is exactly what this disorder lacks. Goals, values, career plans and friendships shift repeatedly, and clients often say plainly that they do not know who they are. Option b is incorrect because week long autonomous mood episodes point to a different diagnosis. Affective instability here runs in hours, swings several times a day, and is almost always set off by something interpersonal. Option d is incorrect because blunted emotional response and indifference to separation describe schizoid detachment. Clients with this disorder react to looming separation with frantic effort, not with an absence of feeling.

Correct Answer: Provide the required physical care calmly and quietly

Physical injury comes first, and care is given in a quiet, matter-of-fact way without lecturing or alarm. Treating the injury is never withheld, and a low key response gives the behavior the least reinforcement. Option b is incorrect because the chain analysis belongs after the client is medically stable. Questioning her while a crowd watches adds an audience, raises emotion and produces little useful information about what triggered the urge. Option c is incorrect because moralizing shames the client and treats a serious act as a bid for notice. Self-injury in this population predicts later suicide, so dismissing it outright is both inaccurate and unsafe. Option d is incorrect because charting waits until the client is safe and cared for. A thorough record of the event, the assessment and the client's own words follows the intervention rather than delaying it.

Correct Answer: "It sounds exhausting to hold everything together. What has that cost you?"

Reflecting the burden and inviting her to look at its cost keeps the door open, addresses her own needs, and lets her examine the caretaking pattern without being criticized for it. Option a is incorrect because an order to stop rescuing is advice delivered as criticism. The wife hears blame, defends herself, and the conversation about what the pattern costs her never gets started. Option b is incorrect because a question opening with why demands justification and puts the wife on the defensive. Therapeutic exploration invites her to describe her experience instead of arguing for her past choices. Option d is incorrect because false reassurance closes the subject. Telling her that things usually sort themselves out dismisses a family pattern that needs direct attention and leaves her without help or a referral.

Correct Answer: Hand tremor, anxiety, sweating and tachycardia

Minor alcohol withdrawal begins six to twelve hours after the last drink with tremor starting in the hands, anxiety, nausea, sweating, tachycardia and hypertension while the client stays oriented. Option b is incorrect because clouded sensorium with fever and autonomic storm describes delirium tremens, which arrives two to four days out. At eight hours the client should still know where he is. Option c is incorrect because constricted pupils with sedation and depressed breathing point to opioid intoxication. Alcohol withdrawal drives the nervous system in the opposite direction, toward arousal rather than depression. Option d is incorrect because a slowed pulse, low blood pressure and heavy sleep fit the crash that follows stimulant use. Alcohol leaving the body produces the reverse picture of speeding up.

Correct Answer: "Coming back took effort. What can we learn from that evening?"

Recurrence is expected in a chronic relapsing condition and is treated as a learning event, not a failure. Affirming his return and examining what happened rebuilds confidence and sharpens the relapse prevention plan. Option a is incorrect because sweeping the episode aside offers comfort without learning. He loses the chance to identify the trigger that caught him, and the same situation will catch him again. Option b is incorrect because normalizing the event while telling him to move on minimizes what he is feeling. Shame left unspoken often drives a single slip into a full return to previous use. Option c is incorrect because a question framed this way sounds like an accusation. He answers by defending his judgment instead of describing the evening, and the useful detail never reaches the nurse.

Correct Answer: Repeated deceit paired with an absence of remorse

Deceitfulness and lack of remorse anchor the diagnosis, alongside disregard for the rights of others since age fifteen, adult age at diagnosis, and evidence of conduct disorder in childhood. Option b is incorrect because desperate attempts to hold on to a relationship belong to borderline personality disorder. This client exploits relationships for gain and shows no distress when one of them ends. Option c is incorrect because events that feel personally meaningful and beliefs in a sixth sense mark schizotypal personality disorder in cluster A. Nothing in this history suggests perceptual oddity or eccentric thinking. Option d is incorrect because rigid perfectionism that blocks completion sits in cluster C with obsessive compulsive personality disorder. That client is preoccupied with rules; this one breaks them without hesitation.

Correct Answer: "Everyone here works from the same plan; I'll help you talk with her."

Restating that all staff work from one shared plan blocks the split, and offering to help the client raise her concern directly keeps the nurse out of the middle of it. Option a is incorrect because accepting the role of the special nurse starts the cycle. Feeling uniquely valued leads staff to stretch a rule, which makes care inconsistent and confirms the client's belief that people cannot be relied on. Option b is incorrect because defending a colleague argues with the feeling instead of addressing the pattern. The client hears dismissal, the devalued nurse is still discussed behind her back, and nothing changes about the divided team. Option d is incorrect because asking why demands an explanation the client cannot give and invites more criticism of another staff member. It also signals agreement that the day nurse behaved coldly.

Correct Answer: "The dietitian set this tray, and I will sit with you."

The pre plated meal is not open to negotiation, and the nurse states that plainly while offering support through the anxiety. Bargaining over portions hands the illness control of the meal. Option a is incorrect because a single exception teaches the client that the plan bends under pressure. Every staff member then faces the same request, and consistency across the team collapses. Option b is incorrect because the words are technically correct yet delivered as a challenge. Framing the meal as a contest invites the client to fight it rather than sit with the feeling. Option c is incorrect because asking why at the table pulls the conversation straight into food content. Questions about calories and portions raise anxiety at the moment the client most needs steadiness.

Correct Answer: The low serum potassium level

A potassium this low sets up ventricular arrhythmia, and cardiac events are the leading cause of death in this illness. The skin, nail and bowel findings are expected and are not immediately lethal. Option a is incorrect because that soft downy hair is simply the body insulating itself after subcutaneous fat is lost. It signals chronic undernutrition and resolves with nutrition, threatening nothing acutely. Option b is incorrect because slowed transit is nearly universal with restriction and is managed with a bowel regimen. Discomfort deserves attention, though it never competes with a rhythm threatening electrolyte. Option d is incorrect because nail changes track protein and mineral depletion over months. They confirm how long the client has been ill without adding anything to the immediate risk picture.

Correct Answer: "I'll state the limit calmly and apply it every shift."

Limits work when they are stated in a calm neutral voice and applied the same way by every staff member on every shift. Consistency, not force, is what makes the limit hold. Option a is incorrect because repeating the rationale invites debate, and debate is what the testing is aiming for. State the limit once, restate it once, then step away from the argument. Option c is incorrect because a single exception resets the whole system. An unenforced limit teaches the client that rules are opening offers, and the next request will arrive larger and aimed at a different nurse. Option d is incorrect because a threat delivered in the moment is punitive rather than planned. Consequences belong in writing at admission, tied to specific behavior, so the client already knows them before any rule is broken.

Correct Answer: Wernicke encephalopathy from thiamine deficiency

Confusion, nystagmus or eye movement palsy, and ataxia form the classic triad of Wernicke encephalopathy, caused by acute thiamine deficiency. Treatment is urgent because the damage is still reversible at this stage. Option b is incorrect because Korsakoff syndrome centers on memory: the client cannot lay down new memories and fills the gaps with invented detail. Eye movement abnormality and ataxia are not its hallmarks. Option c is incorrect because delirium tremens arrives days after the last drink with fluctuating delirium, hallucinations and a body in autonomic overdrive. Nothing here describes fever, drenching sweat or a racing heart. Option d is incorrect because hepatic encephalopathy produces asterixis, jaundice and progressive drowsiness as ammonia climbs. Its neurologic picture lacks the paired eye findings and staggering gait that point straight at thiamine depletion.

Correct Answer: Cross tolerance at the same receptor complex

Alcohol and benzodiazepines both act on the GABA receptor complex, so tolerance built to one carries over to the other. Cross tolerance is why withdrawal in this client demands larger than usual dosing. Option a is incorrect because psychological dependence describes craving and the conviction that one cannot cope without drinking. It is a subjective experience and cannot change how much medication the nervous system requires. Option b is incorrect because heavy drinking damages the liver and usually slows drug metabolism rather than speeding it. Faster clearance would shorten the effect of each dose, not raise the amount needed from the start. Option c is incorrect because dependence on the benzodiazepine cannot exist before the client has ever received it. The heightened requirement was present at the first dose and came from years of drinking.

Correct Answer: Ask directly about thoughts of suicide

The stimulant crash carries genuine suicide risk, and this client has voiced hopelessness. Asking directly about suicidal thoughts is the assessment that must come first, followed by staying with him and alerting the team. Option b is incorrect because sleep is expected during the crash and offering it here sidesteps what the client just said. Encouraging rest leaves him alone at the very moment risk needs to be assessed. Option c is incorrect because promising that the mood will improve is false reassurance that closes the conversation. The client hears that his despair is not worth discussing, and the nurse never learns whether a plan exists. Option d is incorrect because charting a statement of this weight without acting on it abandons the client. Documentation matters, but it follows direct assessment, continuous observation and notification of the treatment team.

Correct Answer: State the facts calmly without arguing the point

A matter of fact, non judgmental presentation of the record leaves the client nothing to fight. Facts stated without moralizing let him look at the pattern himself, which is how denial loosens. Option a is incorrect because labeling the client hands him a fight instead of a fact. Naming denial out loud sounds like an accusation, and the defense he mounts in reply grows firmer with every exchange. Option b is incorrect because silence lets the admission pass without any link being drawn between the crash and the drinking. Waiting for the client to open the subject wastes the one moment he is most reachable. Option d is incorrect because leading with family harm carries a moral charge the client will hear as blame. Guilt raises resistance, and the nurse ends up defending the accusation rather than exploring the pattern.

Correct Answer: The client with the very low pulse

Severe bradycardia signals a starved myocardium and unstable circulation, and cardiac complications are the leading cause of death in anorexia nervosa. Physiologic instability outranks every distressing but stable psychosocial concern. Option a is incorrect because a refused snack is handled through the meal plan and the agreed supplement, not as an emergency. It needs a response within the hour, not before a failing heart. Option c is incorrect because distress about body shape is expected in this illness and does not threaten circulation. Tears identify a client who needs support soon, not the one closest to collapse. Option d is incorrect because avoiding group is a treatment engagement issue that the team addresses later in the day. Nothing about missed group work carries the immediate mortality risk of profound bradycardia.

Correct Answer: A core temperature that keeps climbing

Hyperthermia is the stimulant complication that kills, driving dysrhythmias, seizures, muscle breakdown and organ failure. A climbing core temperature needs immediate reporting, active cooling and fluids rather than watchful waiting. Option a is incorrect because widened pupils and a dry mouth are ordinary sympathetic effects of the drug. They are documented and monitored, yet neither one signals the organ damage that a soaring temperature announces. Option b is incorrect because formication, the sensation of bugs under the skin, is a classic stimulant experience. It calls for calm reassurance and skin inspection for scratching, not an urgent call to the provider. Option c is incorrect because appetite disappears while a stimulant is on board, so a refused tray is expected. Nutrition becomes a concern over the following days, not during the acute agitated phase.

Correct Answer: Tolerance, a physiologic adaptation to repeated exposure

Needing more of a drug for the same effect, or getting less effect from the same amount, defines tolerance. It is a predictable physiologic adaptation of repeated exposure and does not by itself signal addiction. Option b is incorrect because addiction is a behavioral diagnosis built on loss of control, craving and continued use despite harm. This client is simply reporting reduced drug effect and has shown none of those features. Option c is incorrect because withdrawal appears only when the drug is stopped or cut back, producing symptoms opposite to the drug's own action. Nothing here suggests the medication was reduced or held. Option d is incorrect because cross tolerance describes tolerance to one substance carrying over to another in the same class, such as alcohol and benzodiazepines. Only a single medication is involved in this scenario.

Correct Answer: The client tremulous two days after drinking

Two days out from the last drink puts this client in the window for delirium tremens and seizures, the withdrawal that carries a real death rate. Depressant withdrawal outranks the others every time. Option a is incorrect because vomiting during opioid withdrawal is miserable and needs antiemetics and fluids, yet it seldom threatens life in a healthy adult. This client can be seen after the unstable one. Option b is incorrect because heavy sleep is the expected crash after stimulant use, with fatigue and hunger dominating. The nurse watches this client for low mood and suicidal thinking, but not for an airway emergency. Option d is incorrect because cannabis withdrawal brings irritability, poor sleep and reduced appetite without physiologic danger. Reassurance and comfort measures serve this client well, and the visit can wait until the higher risk client is checked.