RN VATI Mental Health 2019 Assessment |
Mental Health Assessment_UPDATED
2022/2023
Section 1: Therapeutic Communication and Nurse-Client Relationship
1. A nurse is performing an admission assessment for a client who appears withdrawn and
fearful. Which of the following actions should the nurse take first?
A. Ask the client why they are fearful
B. Inform the client that this admission is confidential
C. Reassure the client that everything will be okay
D. Proceed with the admission questions quickly
Correct Answer: B
Rationale: According to evidence-based practice, the nurse should first inform the client
about confidentiality during the orientation phase of the nurse-client relationship. This action
establishes trust between the client and the nurse, which in turn decreases the client's anxiety
level. Asking "why" is a non-therapeutic communication technique that can make the client feel
defensive. False reassurance dismisses the client's feelings. Rushing through questions increases
anxiety and does not establish rapport .
2. A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have
I done any permanent damage to my body?" Which of the following responses should the
nurse make?
A. "You shouldn't worry about that right now."
B. "Let's focus on getting you better instead."
C. "You're afraid you have caused physical injury to yourself?"
D. "I'll ask the provider to explain the long-term effects."
Correct Answer: C
Rationale: This response uses therapeutic communication by restating the main idea of
what the client has said, which allows for clarification of any misunderstanding. It validates the
client's concern and encourages further expression. Option A dismisses the client's concern.
,Option B changes the subject and avoids addressing the client's fear. Option D, while referral is
appropriate, the nurse should first address the client's immediate concern .
3. A client with borderline personality disorder tells the nurse, "You're the only nurse who
understands me. The other nurses are terrible." Which of the following responses is most
therapeutic?
A. "I'm glad you feel comfortable with me."
B. "You seem to be splitting the staff into good and bad."
C. "Tell me more about what makes the other nurses terrible."
D. "I will share your concerns with the other nurses."
Correct Answer: B
Rationale: Clients with borderline personality disorder often use splitting (viewing people as
all good or all bad). The therapeutic response is to gently point out this pattern without
judgment, helping the client develop more integrated thinking. Option A reinforces the splitting
behavior. Option C encourages the client to elaborate on splitting. Option D may create conflict
and does not address the underlying issue .
4. A nurse is caring for a client who states, "I don't think I can handle this anymore." Which of
the following therapeutic communication techniques should the nurse use?
A. "I know exactly how you feel."
B. "You can't handle what anymore?"
C. "Things will get better soon."
D. "Have you talked to your family about this?"
Correct Answer: B
Rationale: This response uses the therapeutic technique of clarification, which helps the
nurse understand the client's specific concern without making assumptions. It encourages the
client to elaborate on their feelings. Option A is false empathy; the nurse cannot know exactly
how the client feels. Option C is false reassurance that dismisses the client's current distress.
Option D changes the subject to family and avoids exploring the client's immediate concern .
5. A nurse on a mental health unit is conducting a one-on-one session with a client who
suddenly becomes silent. Which of the following responses should the nurse make?
,A. "Why are you silent?"
B. "I've noticed you've become quiet. Take your time."
C. "We need to continue with the session."
D. "Are you angry with me?"
Correct Answer: B
Rationale: This response uses the therapeutic technique of offering self and giving
recognition. It acknowledges the client's silence without pressure and allows the client time to
process their thoughts. Asking "why" can be perceived as confrontational. Option C dismisses
the client's need for silence. Option D makes an assumption about the client's feelings .
6. A nurse is caring for a client who has been diagnosed with major depressive disorder. The
client states, "I just want to be left alone." Which therapeutic communication response by the
nurse is most appropriate?
A. "You should really try to interact with the other clients; it will help you feel better."
B. "I'll sit here with you for a while. You don't have to talk if you don't want to."
C. "Why do you want to be left alone? Can you explain what's bothering you?"
D. "Being alone will just make your depression worse. Let's go to group therapy."
Correct Answer: B
Rationale: Offering self through silent presence respects the client's need for space while
maintaining therapeutic engagement. Option A gives advice and Option D uses false
reassurance with judgment. Option C asks a "why" question, which is contraindicated because it
can feel interrogative and increase the client's defensiveness .
7. A client with terminal cancer says to the nurse, "I'm going to die, and I wish my family
would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one
who's dying." Which response by the nurse is therapeutic?
A. "Have you shared your feelings with your family?"
B. "I think we should talk more about your anger with your family."
C. "You're feeling angry that your family continues to hope for you to be cured?"
D. "You are probably very depressed, which is understandable with such a diagnosis."
Correct Answer: C
, Rationale: This response uses restatement and reflection to validate the client's feelings.
Option A may be premature. Option B directs the conversation. Option D labels the client's
emotions, which is non-therapeutic .
8. A nurse is caring for an adult client who was involuntarily admitted following a suicide
attempt. The nurse receives a call from the client's spouse asking for a status report. Which of
the following responses should the nurse make?
A. "I cannot discuss your spouse's health information with you without his consent."
B. "Let me transfer you to the provider who can give you that information."
C. "Your spouse is stable right now, but I can't give you more details."
D. "You'll need to come to the facility in person to get that information."
Correct Answer: A
Rationale: HIPAA protects a client's privacy regardless of admission status. The client can
approve individuals with whom the nurse can share information. Releasing protected health
information without permission from the client is an invasion of privacy and a HIPAA violation.
Options B, C, and D all potentially violate the client's privacy rights .
9. A nurse is providing teaching about levels of anxiety to a group of clients who have anxiety
disorders. Which of the following statements should the nurse include?
A. "Mild anxiety causes headaches and insomnia."
B. "Moderate anxiety causes somatic manifestations such as urinary frequency and muscle
tension."
C. "Severe anxiety enhances learning and problem-solving."
D. "Panic-level anxiety improves concentration."
Correct Answer: B
Rationale: Somatic manifestations begin during moderate anxiety. Clients can experience
urinary frequency, muscle tension, and headaches. Mild anxiety actually enhances learning and
problem-solving. Severe anxiety impairs learning, and panic-level anxiety causes severe
disorganization .
Mental Health Assessment_UPDATED
2022/2023
Section 1: Therapeutic Communication and Nurse-Client Relationship
1. A nurse is performing an admission assessment for a client who appears withdrawn and
fearful. Which of the following actions should the nurse take first?
A. Ask the client why they are fearful
B. Inform the client that this admission is confidential
C. Reassure the client that everything will be okay
D. Proceed with the admission questions quickly
Correct Answer: B
Rationale: According to evidence-based practice, the nurse should first inform the client
about confidentiality during the orientation phase of the nurse-client relationship. This action
establishes trust between the client and the nurse, which in turn decreases the client's anxiety
level. Asking "why" is a non-therapeutic communication technique that can make the client feel
defensive. False reassurance dismisses the client's feelings. Rushing through questions increases
anxiety and does not establish rapport .
2. A nurse is caring for an adolescent client who has anorexia nervosa. The client states, "Have
I done any permanent damage to my body?" Which of the following responses should the
nurse make?
A. "You shouldn't worry about that right now."
B. "Let's focus on getting you better instead."
C. "You're afraid you have caused physical injury to yourself?"
D. "I'll ask the provider to explain the long-term effects."
Correct Answer: C
Rationale: This response uses therapeutic communication by restating the main idea of
what the client has said, which allows for clarification of any misunderstanding. It validates the
client's concern and encourages further expression. Option A dismisses the client's concern.
,Option B changes the subject and avoids addressing the client's fear. Option D, while referral is
appropriate, the nurse should first address the client's immediate concern .
3. A client with borderline personality disorder tells the nurse, "You're the only nurse who
understands me. The other nurses are terrible." Which of the following responses is most
therapeutic?
A. "I'm glad you feel comfortable with me."
B. "You seem to be splitting the staff into good and bad."
C. "Tell me more about what makes the other nurses terrible."
D. "I will share your concerns with the other nurses."
Correct Answer: B
Rationale: Clients with borderline personality disorder often use splitting (viewing people as
all good or all bad). The therapeutic response is to gently point out this pattern without
judgment, helping the client develop more integrated thinking. Option A reinforces the splitting
behavior. Option C encourages the client to elaborate on splitting. Option D may create conflict
and does not address the underlying issue .
4. A nurse is caring for a client who states, "I don't think I can handle this anymore." Which of
the following therapeutic communication techniques should the nurse use?
A. "I know exactly how you feel."
B. "You can't handle what anymore?"
C. "Things will get better soon."
D. "Have you talked to your family about this?"
Correct Answer: B
Rationale: This response uses the therapeutic technique of clarification, which helps the
nurse understand the client's specific concern without making assumptions. It encourages the
client to elaborate on their feelings. Option A is false empathy; the nurse cannot know exactly
how the client feels. Option C is false reassurance that dismisses the client's current distress.
Option D changes the subject to family and avoids exploring the client's immediate concern .
5. A nurse on a mental health unit is conducting a one-on-one session with a client who
suddenly becomes silent. Which of the following responses should the nurse make?
,A. "Why are you silent?"
B. "I've noticed you've become quiet. Take your time."
C. "We need to continue with the session."
D. "Are you angry with me?"
Correct Answer: B
Rationale: This response uses the therapeutic technique of offering self and giving
recognition. It acknowledges the client's silence without pressure and allows the client time to
process their thoughts. Asking "why" can be perceived as confrontational. Option C dismisses
the client's need for silence. Option D makes an assumption about the client's feelings .
6. A nurse is caring for a client who has been diagnosed with major depressive disorder. The
client states, "I just want to be left alone." Which therapeutic communication response by the
nurse is most appropriate?
A. "You should really try to interact with the other clients; it will help you feel better."
B. "I'll sit here with you for a while. You don't have to talk if you don't want to."
C. "Why do you want to be left alone? Can you explain what's bothering you?"
D. "Being alone will just make your depression worse. Let's go to group therapy."
Correct Answer: B
Rationale: Offering self through silent presence respects the client's need for space while
maintaining therapeutic engagement. Option A gives advice and Option D uses false
reassurance with judgment. Option C asks a "why" question, which is contraindicated because it
can feel interrogative and increase the client's defensiveness .
7. A client with terminal cancer says to the nurse, "I'm going to die, and I wish my family
would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one
who's dying." Which response by the nurse is therapeutic?
A. "Have you shared your feelings with your family?"
B. "I think we should talk more about your anger with your family."
C. "You're feeling angry that your family continues to hope for you to be cured?"
D. "You are probably very depressed, which is understandable with such a diagnosis."
Correct Answer: C
, Rationale: This response uses restatement and reflection to validate the client's feelings.
Option A may be premature. Option B directs the conversation. Option D labels the client's
emotions, which is non-therapeutic .
8. A nurse is caring for an adult client who was involuntarily admitted following a suicide
attempt. The nurse receives a call from the client's spouse asking for a status report. Which of
the following responses should the nurse make?
A. "I cannot discuss your spouse's health information with you without his consent."
B. "Let me transfer you to the provider who can give you that information."
C. "Your spouse is stable right now, but I can't give you more details."
D. "You'll need to come to the facility in person to get that information."
Correct Answer: A
Rationale: HIPAA protects a client's privacy regardless of admission status. The client can
approve individuals with whom the nurse can share information. Releasing protected health
information without permission from the client is an invasion of privacy and a HIPAA violation.
Options B, C, and D all potentially violate the client's privacy rights .
9. A nurse is providing teaching about levels of anxiety to a group of clients who have anxiety
disorders. Which of the following statements should the nurse include?
A. "Mild anxiety causes headaches and insomnia."
B. "Moderate anxiety causes somatic manifestations such as urinary frequency and muscle
tension."
C. "Severe anxiety enhances learning and problem-solving."
D. "Panic-level anxiety improves concentration."
Correct Answer: B
Rationale: Somatic manifestations begin during moderate anxiety. Clients can experience
urinary frequency, muscle tension, and headaches. Mild anxiety actually enhances learning and
problem-solving. Severe anxiety impairs learning, and panic-level anxiety causes severe
disorganization .
