NU 160 Exam 1 V2 | NU 160 Mental Health
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 1)
1. A nurse is conducting a mental status examination (MSE) on a client with depression.
Which of the following components should the nurse include in the assessment of the client’s
‘thought process’?
A. The client’s ability to perform simple mathematical calculations.
B. The organization and flow of the client’s speech and ideas.
C. The client’s awareness of time, place, and person.
D. The client’s stated mood and emotional state.
Correct Answer: B
Explanation: Thought process refers to how a client thinks, including the organization,
logic, and coherence of their ideas. Assessing the flow of speech helps identify
abnormalities like flight of ideas or tangentiality. This differs from thought content, which
focuses on what the client is actually saying.
2. A client is being admitted involuntarily to a psychiatric unit after threatening to harm a
neighbor. Which legal principle justifies this admission?
A. Autonomy
B. Beneficence
,C. Dangerousness to others
D. The right to the least restrictive environment
Correct Answer: C
Explanation: Involuntary admission is legally permitted when a client poses an immediate
danger to themselves or others. This process balances individual rights with the need for
public safety and professional duty. The nurse must document specific threats or behaviors
that justify the restriction of the client’s liberty.
3. The nurse is communicating with a client who is experiencing moderate anxiety. Which of
the following statements by the nurse is the most therapeutic?
A. ‘Why are you feeling so anxious right now?’
B. ‘You should try to take a deep breath and relax.’
C. ‘What was happening just before you started feeling this way?’
D. ‘Don’t worry, we are here to take care of you and keep you safe.’
Correct Answer: C
Explanation: This open-ended question helps the client identify the stressor or trigger for
their anxiety. Moderate anxiety allows for some level of cognitive processing and problem-
solving. By identifying the cause, the nurse and client can work together on coping
strategies.
, 4. A client frequently displaces their anger toward their spouse onto the nursing staff. Which
defense mechanism is the client utilizing?
A. Projection
B. Reaction Formation
C. Displacement
D. Sublimation
Correct Answer: C
Explanation: Displacement involves transferring emotions from a threatening or
inaccessible target to a less threatening one. In this case, the client is venting frustration on
the staff instead of the spouse. Recognizing this helps the nurse maintain a professional
boundary and avoid taking the anger personally.
5. A nurse is caring for a client who is in the working phase of the nurse-client relationship.
Which of the following actions should the nurse prioritize?
A. Establishing the parameters and duration of the relationship.
B. Promoting the client’s problem-solving skills and self-esteem.
C. Summarizing the goals achieved during the relationship.
D. Discussing the client’s expectations for the admission.
Correct Answer: B
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 1)
1. A nurse is conducting a mental status examination (MSE) on a client with depression.
Which of the following components should the nurse include in the assessment of the client’s
‘thought process’?
A. The client’s ability to perform simple mathematical calculations.
B. The organization and flow of the client’s speech and ideas.
C. The client’s awareness of time, place, and person.
D. The client’s stated mood and emotional state.
Correct Answer: B
Explanation: Thought process refers to how a client thinks, including the organization,
logic, and coherence of their ideas. Assessing the flow of speech helps identify
abnormalities like flight of ideas or tangentiality. This differs from thought content, which
focuses on what the client is actually saying.
2. A client is being admitted involuntarily to a psychiatric unit after threatening to harm a
neighbor. Which legal principle justifies this admission?
A. Autonomy
B. Beneficence
,C. Dangerousness to others
D. The right to the least restrictive environment
Correct Answer: C
Explanation: Involuntary admission is legally permitted when a client poses an immediate
danger to themselves or others. This process balances individual rights with the need for
public safety and professional duty. The nurse must document specific threats or behaviors
that justify the restriction of the client’s liberty.
3. The nurse is communicating with a client who is experiencing moderate anxiety. Which of
the following statements by the nurse is the most therapeutic?
A. ‘Why are you feeling so anxious right now?’
B. ‘You should try to take a deep breath and relax.’
C. ‘What was happening just before you started feeling this way?’
D. ‘Don’t worry, we are here to take care of you and keep you safe.’
Correct Answer: C
Explanation: This open-ended question helps the client identify the stressor or trigger for
their anxiety. Moderate anxiety allows for some level of cognitive processing and problem-
solving. By identifying the cause, the nurse and client can work together on coping
strategies.
, 4. A client frequently displaces their anger toward their spouse onto the nursing staff. Which
defense mechanism is the client utilizing?
A. Projection
B. Reaction Formation
C. Displacement
D. Sublimation
Correct Answer: C
Explanation: Displacement involves transferring emotions from a threatening or
inaccessible target to a less threatening one. In this case, the client is venting frustration on
the staff instead of the spouse. Recognizing this helps the nurse maintain a professional
boundary and avoid taking the anger personally.
5. A nurse is caring for a client who is in the working phase of the nurse-client relationship.
Which of the following actions should the nurse prioritize?
A. Establishing the parameters and duration of the relationship.
B. Promoting the client’s problem-solving skills and self-esteem.
C. Summarizing the goals achieved during the relationship.
D. Discussing the client’s expectations for the admission.
Correct Answer: B
