NU 160 Exam 2 V3 | NU 160 Mental Health
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 2)
1. A client is experiencing a panic attack in the emergency department. Which nursing
intervention is the highest priority?
A. Encourage the client to describe the feelings in detail.
B. Administer a prescribed daily antidepressant.
C. Teach the client deep breathing exercises for future use.
D. Stay with the client and use short, simple sentences.
Correct Answer: D
Explanation: During a panic attack, the client’s perceptual field is significantly narrowed,
making it difficult to process complex information. Staying with the client provides a sense
of safety and reduces the fear of being alone during the crisis. Short, simple sentences are
necessary because the client cannot concentrate on lengthy explanations or instructions in
this state.
2. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends 45
minutes washing hands after touching any surface. What is the most appropriate initial
intervention?
A. Lock the bathroom door to prevent the ritual.
,B. Tell the client that the hands are clean after one wash.
C. Explain the physiological effects of excessive hand washing.
D. Allow the client enough time to perform the ritual initially.
Correct Answer: D
Explanation: Initially, the nurse should allow time for the ritual to prevent a massive
increase in the client’s anxiety levels. Forcing a client to stop a ritual abruptly can lead to
panic and loss of control. The goal is to gradually decrease the time spent on rituals while
teaching new coping mechanisms over time.
3. A client with Post-Traumatic Stress Disorder (PTSD) is being discharged. Which of the
following statements by the client indicates an understanding of the management of
flashbacks? (Select All That Apply)
A. I will try to keep my eyes open during the flashback.
B. I will focus on things in my current environment.
C. I will tell myself that I am safe and the event is over.
D. I should avoid talking about the event to prevent flashbacks.
Correct Answer: A, B, C
Explanation: Grounding techniques are essential for managing flashbacks in PTSD
patients. Keeping eyes open and focusing on the current environment helps the client
, remain in the present reality. Reaffirming safety helps de-escalate the physiological stress
response triggered by the traumatic memory.
4. A client is prescribed Buspirone for Generalized Anxiety Disorder. What information is
critical for the nurse to include in the teaching plan?
A. The medication has a high potential for addiction.
B. The medication should be used only on an as-needed basis.
C. Stop taking the medication immediately if you feel dizzy.
D. It takes 2 to 4 weeks for the full effect to be felt.
Correct Answer: D
Explanation: Buspirone is a non-benzodiazepine anxiolytic that does not have immediate
effects. Patients must be educated that it requires consistent daily dosing and several
weeks to reach therapeutic levels. Unlike benzodiazepines, it is not used for ‘as-needed’
(PRN) relief of acute anxiety.
5. A nurse is assessing a client with Borderline Personality Disorder. Which behavior is the
nurse most likely to observe?
A. Social isolation and lack of interest in relationships.
B. Extreme perfectionism and preoccupation with order.
C. Emotional instability and intense, ‘all-or-nothing’ relationships.
D. Lack of remorse for violating the rights of others.
Concepts | NCLEX (NGN) Q&A with
Rationale (NU160 Exam 2)
1. A client is experiencing a panic attack in the emergency department. Which nursing
intervention is the highest priority?
A. Encourage the client to describe the feelings in detail.
B. Administer a prescribed daily antidepressant.
C. Teach the client deep breathing exercises for future use.
D. Stay with the client and use short, simple sentences.
Correct Answer: D
Explanation: During a panic attack, the client’s perceptual field is significantly narrowed,
making it difficult to process complex information. Staying with the client provides a sense
of safety and reduces the fear of being alone during the crisis. Short, simple sentences are
necessary because the client cannot concentrate on lengthy explanations or instructions in
this state.
2. A nurse is caring for a client with Obsessive-Compulsive Disorder (OCD) who spends 45
minutes washing hands after touching any surface. What is the most appropriate initial
intervention?
A. Lock the bathroom door to prevent the ritual.
,B. Tell the client that the hands are clean after one wash.
C. Explain the physiological effects of excessive hand washing.
D. Allow the client enough time to perform the ritual initially.
Correct Answer: D
Explanation: Initially, the nurse should allow time for the ritual to prevent a massive
increase in the client’s anxiety levels. Forcing a client to stop a ritual abruptly can lead to
panic and loss of control. The goal is to gradually decrease the time spent on rituals while
teaching new coping mechanisms over time.
3. A client with Post-Traumatic Stress Disorder (PTSD) is being discharged. Which of the
following statements by the client indicates an understanding of the management of
flashbacks? (Select All That Apply)
A. I will try to keep my eyes open during the flashback.
B. I will focus on things in my current environment.
C. I will tell myself that I am safe and the event is over.
D. I should avoid talking about the event to prevent flashbacks.
Correct Answer: A, B, C
Explanation: Grounding techniques are essential for managing flashbacks in PTSD
patients. Keeping eyes open and focusing on the current environment helps the client
, remain in the present reality. Reaffirming safety helps de-escalate the physiological stress
response triggered by the traumatic memory.
4. A client is prescribed Buspirone for Generalized Anxiety Disorder. What information is
critical for the nurse to include in the teaching plan?
A. The medication has a high potential for addiction.
B. The medication should be used only on an as-needed basis.
C. Stop taking the medication immediately if you feel dizzy.
D. It takes 2 to 4 weeks for the full effect to be felt.
Correct Answer: D
Explanation: Buspirone is a non-benzodiazepine anxiolytic that does not have immediate
effects. Patients must be educated that it requires consistent daily dosing and several
weeks to reach therapeutic levels. Unlike benzodiazepines, it is not used for ‘as-needed’
(PRN) relief of acute anxiety.
5. A nurse is assessing a client with Borderline Personality Disorder. Which behavior is the
nurse most likely to observe?
A. Social isolation and lack of interest in relationships.
B. Extreme perfectionism and preoccupation with order.
C. Emotional instability and intense, ‘all-or-nothing’ relationships.
D. Lack of remorse for violating the rights of others.
