STUDYSAGE
Focus on Mental Health exam
guide with 100% correct
answers.
A nurse overhears a hospitalized client with mania telling another client, "I'm actually a journalist writing
an article for a magazine — I'm just posing as a person with mental illness." How should the nurse
respond? - correct answer✔️✔️Presenting the client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the
nurse does not share the client's perceptions. All three of the other options — ignoring the delusion,
taking the client to a quiet room, and supporting the client's denial of illness — do not focus on reality,
and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get out." How should
the nurse respond to the client? - correct answer✔️✔️"I know you must be very upset by this, but I
don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the
client's experience, because this may lead to a regressive struggle with the client. Giving advice or false
reassurance is incorrect because such techniques indicate that demons actually are present, which feeds
into the client's hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for picking the
neighbors' flowers." Which defense mechanism was the child using? - correct
answer✔️✔D ️ isplacement
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one
person onto a less threatening substitute person or object to satisfy an impulse. Projection involves
attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or
scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object.
Identification involves modeling behavior after someone else's.
A client says to the nurse, "Even though my husband and I keep telling them we don't want to have
children, our parents are pressuring us to 'start a family.' What should we say to them?" Which of the
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,STUDYSAGE
following responses by the nurse is therapeutic? - correct answer✔️✔️"This must be very difficult for
both of you."
Rationale: Childless families may elect not to have children or to postpone having them until they have
established themselves occupationally or financially. Telling the client to tell the parents that the couple
can't have children is incorrect because the client is being encouraged to lie about life decisions rather
than helping the parents understand the couple's choices. Asking how they usually cope with such
interference is incorrect because it indicates that the nurse is judgmental and has decided that the
parents are interfering with the client and spouse. Saying, "Tell them to have more children if they want
them so badly," is incorrect because it is sarcastic and ridicules the situation over which the client has
expressed concerns.
A young adult client says, "I just can't seem to stop snapping at my parents. I know they work hard to
support me, but what do I do when they're so overbearing?" Which responses by the nurse is
therapeutic? - correct answer✔️✔️"Have you talked to your parents about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages the therapeutic
technique of formulating a plan of action. "It's important not to be rude to your parents" and "You need
to be more patient with your parents" are both nontherapeutic, judgmental responses that do not
encourage the client to further explore her feelings and problem-solve. "Snapping at your parents is
childish. How could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
A client says, "I have so much trouble caring for my husband's child from his first marriage. I resent the
money we have to pay for child support because we have to deprive my own child of things. How can I
stop feeling this way?" Which response by the nurse is therapeutic? - correct answer✔️✔️"Have you
shared your feelings with your husband?"
Rationale: Remarried individuals often encounter problems as a result of the stressors they bring into a
marriage without prior discussion with the new partner. Bonding sometimes does always occur when a
child is not one's biological offspring. The correct answer is focused on the client's feelings. "Your child
benefits from having a sibling" is not facilitative. "I wonder why you married him, knowing that he
wouldn't desert his biological child" is incorrect because it prejudges the client. "You need to take a
second job to give your child what you think she deserves" is not open ended, does not facilitate
feelings, and gives advice.
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,STUDYSAGE
A client says to the nurse, "My wife retired last year from a lucrative law practice, and I'm really
discouraged. I'll be working until I die, even though I helped pay for her education." Which response by
the nurse is supportive? - correct answer✔️✔️"You sound very troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to express
his feelings; nor does "That's such a tough break for you." Suggesting that the husband approach the
spouse for help is incorrect because it prematurely gives advice, a nontherapeutic communication
technique. The correct option is focused on the client's feelings.
A gay man is brought to the emergency department by the police. The client tells the nurse, "I was
beaten up. I guess I just have to expect this kind of treatment for the rest of my life." Which statement
by the nurse is therapeutic? - correct answer✔️✔️"You feel that being beaten up goes along with being
gay?"
Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. "I think
you should take some self-defense classes" is incorrect because it advises the client, and giving advice is
not therapeutic. "Maybe you should be more discreet when you're in public" also gives advice and
presumes that the client has been indiscreet. "Why not try counseling to change your sexual
orientation?" is incorrect because it assumes that sexual orientation can or should be changed. The
correct option indicates reflection and is focused on the client's feelings.
A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has
priority in the plan of care? - correct answer✔️✔A️ ssessing the client's risk for violence toward self and
others
Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the client's
risk for violence toward self and others. Although the nurse will assist the client in resolving the grief
and monitor the client's sleep pattern, these are not the priority interventions of the options given.
Obtaining a prescription for an antidepressant is not a priority.
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is
experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client? Select
all that apply. - correct answer✔️✔️Assisting the client in verbalizing fears
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
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, STUDYSAGE
Rationale: Assisting the client with problem-solving and decision-making, helping the client verbalize
fears, helping the client identify sources of hope, and monitoring the client for signs of self-harm are all
appropriate interventions. In planning care for a client having difficulty adjusting to an illness, the nurse
develops interventions to promote social networking that will provide needed support and information
to the client.
An emergency department nurse is caring for an older client who is a victim of physical abuse. List in
order of priority the following nursing actions, with number 1 representing the first action and number 4
the last. - correct answer✔️✔️1. Checking the client for physical injuries
2. Contacting the appropriate state officials to report the abuse
3. Contacting a social worker to assist in planning care for the client
4. Calling a member of the clergy to address the client's spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the client for physical
injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The next
action is to contact the social worker to obtain assistance in planning care for the client. The client may
need the social worker's help with housing as well. Last, a referral to a member of the clergy is an
appropriate intervention if the client desires it.
The parents of an 18-month-old arrive at the emergency department with their unconscious child.
Physical examination reveals bruises on the child's upper arms that resemble grip marks. Which nursing
intervention is the priority? - correct answer✔️✔️Stabilizing the child's physical condition
Rationale: In all child abuse cases, the primary concern is the physical condition of the child. Although
contacting appropriate state officials to report suspected abuse and securing a safe environment for the
child are both interventions that need to be performed, this child is unconscious, so the priority is to
stabilize the child's physical condition. Confronting the parents about the abuse at this time may cause
resentment and conflict in the parents, and the parents might attempt to leave the emergency
department with their child.
A nurse in a women's clinic develops a plan of care for abused women. Which tertiary prevention
intervention should be included in the plan of care? - correct answer✔️✔️Assisting abused women in
overcoming the physical and psychological effects of abuse
4|Page
Focus on Mental Health exam
guide with 100% correct
answers.
A nurse overhears a hospitalized client with mania telling another client, "I'm actually a journalist writing
an article for a magazine — I'm just posing as a person with mental illness." How should the nurse
respond? - correct answer✔️✔️Presenting the client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the
nurse does not share the client's perceptions. All three of the other options — ignoring the delusion,
taking the client to a quiet room, and supporting the client's denial of illness — do not focus on reality,
and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get out." How should
the nurse respond to the client? - correct answer✔️✔️"I know you must be very upset by this, but I
don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the
client's experience, because this may lead to a regressive struggle with the client. Giving advice or false
reassurance is incorrect because such techniques indicate that demons actually are present, which feeds
into the client's hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for picking the
neighbors' flowers." Which defense mechanism was the child using? - correct
answer✔️✔D ️ isplacement
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one
person onto a less threatening substitute person or object to satisfy an impulse. Projection involves
attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or
scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object.
Identification involves modeling behavior after someone else's.
A client says to the nurse, "Even though my husband and I keep telling them we don't want to have
children, our parents are pressuring us to 'start a family.' What should we say to them?" Which of the
1|Page
,STUDYSAGE
following responses by the nurse is therapeutic? - correct answer✔️✔️"This must be very difficult for
both of you."
Rationale: Childless families may elect not to have children or to postpone having them until they have
established themselves occupationally or financially. Telling the client to tell the parents that the couple
can't have children is incorrect because the client is being encouraged to lie about life decisions rather
than helping the parents understand the couple's choices. Asking how they usually cope with such
interference is incorrect because it indicates that the nurse is judgmental and has decided that the
parents are interfering with the client and spouse. Saying, "Tell them to have more children if they want
them so badly," is incorrect because it is sarcastic and ridicules the situation over which the client has
expressed concerns.
A young adult client says, "I just can't seem to stop snapping at my parents. I know they work hard to
support me, but what do I do when they're so overbearing?" Which responses by the nurse is
therapeutic? - correct answer✔️✔️"Have you talked to your parents about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages the therapeutic
technique of formulating a plan of action. "It's important not to be rude to your parents" and "You need
to be more patient with your parents" are both nontherapeutic, judgmental responses that do not
encourage the client to further explore her feelings and problem-solve. "Snapping at your parents is
childish. How could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
A client says, "I have so much trouble caring for my husband's child from his first marriage. I resent the
money we have to pay for child support because we have to deprive my own child of things. How can I
stop feeling this way?" Which response by the nurse is therapeutic? - correct answer✔️✔️"Have you
shared your feelings with your husband?"
Rationale: Remarried individuals often encounter problems as a result of the stressors they bring into a
marriage without prior discussion with the new partner. Bonding sometimes does always occur when a
child is not one's biological offspring. The correct answer is focused on the client's feelings. "Your child
benefits from having a sibling" is not facilitative. "I wonder why you married him, knowing that he
wouldn't desert his biological child" is incorrect because it prejudges the client. "You need to take a
second job to give your child what you think she deserves" is not open ended, does not facilitate
feelings, and gives advice.
2|Page
,STUDYSAGE
A client says to the nurse, "My wife retired last year from a lucrative law practice, and I'm really
discouraged. I'll be working until I die, even though I helped pay for her education." Which response by
the nurse is supportive? - correct answer✔️✔️"You sound very troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to express
his feelings; nor does "That's such a tough break for you." Suggesting that the husband approach the
spouse for help is incorrect because it prematurely gives advice, a nontherapeutic communication
technique. The correct option is focused on the client's feelings.
A gay man is brought to the emergency department by the police. The client tells the nurse, "I was
beaten up. I guess I just have to expect this kind of treatment for the rest of my life." Which statement
by the nurse is therapeutic? - correct answer✔️✔️"You feel that being beaten up goes along with being
gay?"
Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. "I think
you should take some self-defense classes" is incorrect because it advises the client, and giving advice is
not therapeutic. "Maybe you should be more discreet when you're in public" also gives advice and
presumes that the client has been indiscreet. "Why not try counseling to change your sexual
orientation?" is incorrect because it assumes that sexual orientation can or should be changed. The
correct option indicates reflection and is focused on the client's feelings.
A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has
priority in the plan of care? - correct answer✔️✔A️ ssessing the client's risk for violence toward self and
others
Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the client's
risk for violence toward self and others. Although the nurse will assist the client in resolving the grief
and monitor the client's sleep pattern, these are not the priority interventions of the options given.
Obtaining a prescription for an antidepressant is not a priority.
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is
experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client? Select
all that apply. - correct answer✔️✔️Assisting the client in verbalizing fears
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
3|Page
, STUDYSAGE
Rationale: Assisting the client with problem-solving and decision-making, helping the client verbalize
fears, helping the client identify sources of hope, and monitoring the client for signs of self-harm are all
appropriate interventions. In planning care for a client having difficulty adjusting to an illness, the nurse
develops interventions to promote social networking that will provide needed support and information
to the client.
An emergency department nurse is caring for an older client who is a victim of physical abuse. List in
order of priority the following nursing actions, with number 1 representing the first action and number 4
the last. - correct answer✔️✔️1. Checking the client for physical injuries
2. Contacting the appropriate state officials to report the abuse
3. Contacting a social worker to assist in planning care for the client
4. Calling a member of the clergy to address the client's spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the client for physical
injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The next
action is to contact the social worker to obtain assistance in planning care for the client. The client may
need the social worker's help with housing as well. Last, a referral to a member of the clergy is an
appropriate intervention if the client desires it.
The parents of an 18-month-old arrive at the emergency department with their unconscious child.
Physical examination reveals bruises on the child's upper arms that resemble grip marks. Which nursing
intervention is the priority? - correct answer✔️✔️Stabilizing the child's physical condition
Rationale: In all child abuse cases, the primary concern is the physical condition of the child. Although
contacting appropriate state officials to report suspected abuse and securing a safe environment for the
child are both interventions that need to be performed, this child is unconscious, so the priority is to
stabilize the child's physical condition. Confronting the parents about the abuse at this time may cause
resentment and conflict in the parents, and the parents might attempt to leave the emergency
department with their child.
A nurse in a women's clinic develops a plan of care for abused women. Which tertiary prevention
intervention should be included in the plan of care? - correct answer✔️✔️Assisting abused women in
overcoming the physical and psychological effects of abuse
4|Page
