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UNIT 4: FOUNDATIONS OF PSYCHIATRIC
NURSING | CERTIFIED EXAM QUESTIONS AND
ANSWERS| GUARANTEED SUCCESS | 2025
What client behaviors would be most important for the nurse to consider in
deciding to institute suicide precautions because of high-risk behavior? - Correct-
answer-The client recently attempted suicide with a lethal method.
A recent suicide attempt using a lethal method always indicates the need for
suicide precautions. The client is at high risk for suicide, and his life must be
protected and safety maintained.Having feelings of being in control of suicidal
thoughts, worrying about a child's reaction, or expressing guilt and shame about a
suicide attempt indicates a lower risk for suicide.
The nurse who uses self-disclosure should: - Correct-answer-refocus on the
client's experience as quickly as possible.
The nurse's self-disclosure should be brief and to the point so that the interaction
can be refocused on the client's experience. Because the client is the focus of the
nurse-client relationship, discussion shouldn't dwell on the nurse's experience.
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A 6-year-old client is diagnosed with attention deficit hyperactivity disorder
(ADHD). When asking this client to complete a task, what techniques should the
nurse use to communicate mosteffectively with him? - Correct-answer-Obtain eye
contact before speaking, use simple language, and have him repeat what was
said. Praise him if he completes the task.
Because the client with ADHD is easily distractible, it is important to obtain eye
contact before explaining the task. Simple language and having him repeat what
he is told are necessary because of his age. Praise encourages the client to repeat
the task in the future as well as building the client's self-esteem. A full explanation
with verbal praise and a food reward is inappropriate because a food reward
increases the chance that he will expect a physical reward for completing tasks. In
addition, a full explanation might be too confusing for someone his age.
Explaining consequences focuses on punishment, rather than praise. Although
demonstration and imitation is an effective teaching method, rewarding with
food fosters dependence on food reward for task completion.
As the nurse stands near the window in the client's room, the client shouts,
"Come away from the window! They will see you!" Which response by the nurse
would be best? - Correct-answer-"Who are 'they'?"
Asking the client who "they" are when he is fearful helps the nurse understand his
behavior and is least demanding of the client. The client is unlikely to accept
statements that indicate that no one will see the nurse. The client is unlikely to
accept statements that there is no reason to be afraid. Asking the client what will
happen if someone sees the nurse is also unlikely to be acceptable and validates
the client's delusion.
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Nursing implications for a client taking central nervous system (CNS) stimulants
include monitoring the client for which conditions? - Correct-answer-tachycardia,
weight loss, and mood swings
Stimulants produce mood swings, anorexia and weight loss, and tachycardia.
Hyperpyrexia, slow pulse, weight gain, hypotension, listlessness, increased
appetite, slowing of sensorium, and arrhythmias indicate CNS depression.
A client refuses the evening dose of haloperidol and then becomes extremely
agitated in the day room while other clients are watching television. The client
begins cursing and throwing furniture. The nurse's first action is to: - Correct-
answer-remove all other clients from the day room.
The nurse's first priority is to consider the safety of the clients in the therapeutic
setting. Checking for an as-needed drug order and calling the physician are
appropriate responses after ensuring the safety of other individuals. Because the
client poses a danger to self and others, restraints may be used; however, less
restrictive interventions should be attempted first.
The nurse understands that with the right help at the right time, a client can
successfully resolve a crisis and function better than before the crisis, based
primarily on which factor? - Correct-answer-acquisition of new coping skills
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Learning new coping skills is the major factor necessary for higher functioning.
Better coping is likely to lead to regaining support systems, giving up
dysfunctional coping, and awareness of how to prevent future crises.
A client is admitted for a surgical biopsy of a suspicious lump in the right breast.
At the time the nurse arrives to take the client to surgery, the client is finishing a
letter to the client's children. The client tearfully tells the nurse, "I just want to
leave this for my children in case anything goes wrong in the surgery." Which
nursing response will be most therapeutic? - Correct-answer-What are you
concerned about right now?"
The most therapeutic response is one in which the nurse reflects back to the
client what the client has said and asks the client to reflect further. Making light of
the client's worries about the biopsy does not help the client process their
feelings or concerns. The client did not express questions about the biopsy;
therefore calling the doctor is not appropriate at this time. Confronting the client
about what the nurse feels is misplaced anxiety of the biopsy versus cancer would
not be beneficial to the client and not therapeutic in these circumstances.
Several former clients from a mental health facility have recently collected their
stories to corroborate that a nurse working there has attempted to befriend
them. The clients state that during their therapy, the nurse encouraged them to
invest in a new business. The nursing supervisor, upon hearing of the clients'
reports, begins an investigation. How can the nursing supervisor best describe the
UNIT 4: FOUNDATIONS OF PSYCHIATRIC
NURSING | CERTIFIED EXAM QUESTIONS AND
ANSWERS| GUARANTEED SUCCESS | 2025
What client behaviors would be most important for the nurse to consider in
deciding to institute suicide precautions because of high-risk behavior? - Correct-
answer-The client recently attempted suicide with a lethal method.
A recent suicide attempt using a lethal method always indicates the need for
suicide precautions. The client is at high risk for suicide, and his life must be
protected and safety maintained.Having feelings of being in control of suicidal
thoughts, worrying about a child's reaction, or expressing guilt and shame about a
suicide attempt indicates a lower risk for suicide.
The nurse who uses self-disclosure should: - Correct-answer-refocus on the
client's experience as quickly as possible.
The nurse's self-disclosure should be brief and to the point so that the interaction
can be refocused on the client's experience. Because the client is the focus of the
nurse-client relationship, discussion shouldn't dwell on the nurse's experience.
,2|Page
A 6-year-old client is diagnosed with attention deficit hyperactivity disorder
(ADHD). When asking this client to complete a task, what techniques should the
nurse use to communicate mosteffectively with him? - Correct-answer-Obtain eye
contact before speaking, use simple language, and have him repeat what was
said. Praise him if he completes the task.
Because the client with ADHD is easily distractible, it is important to obtain eye
contact before explaining the task. Simple language and having him repeat what
he is told are necessary because of his age. Praise encourages the client to repeat
the task in the future as well as building the client's self-esteem. A full explanation
with verbal praise and a food reward is inappropriate because a food reward
increases the chance that he will expect a physical reward for completing tasks. In
addition, a full explanation might be too confusing for someone his age.
Explaining consequences focuses on punishment, rather than praise. Although
demonstration and imitation is an effective teaching method, rewarding with
food fosters dependence on food reward for task completion.
As the nurse stands near the window in the client's room, the client shouts,
"Come away from the window! They will see you!" Which response by the nurse
would be best? - Correct-answer-"Who are 'they'?"
Asking the client who "they" are when he is fearful helps the nurse understand his
behavior and is least demanding of the client. The client is unlikely to accept
statements that indicate that no one will see the nurse. The client is unlikely to
accept statements that there is no reason to be afraid. Asking the client what will
happen if someone sees the nurse is also unlikely to be acceptable and validates
the client's delusion.
,3|Page
Nursing implications for a client taking central nervous system (CNS) stimulants
include monitoring the client for which conditions? - Correct-answer-tachycardia,
weight loss, and mood swings
Stimulants produce mood swings, anorexia and weight loss, and tachycardia.
Hyperpyrexia, slow pulse, weight gain, hypotension, listlessness, increased
appetite, slowing of sensorium, and arrhythmias indicate CNS depression.
A client refuses the evening dose of haloperidol and then becomes extremely
agitated in the day room while other clients are watching television. The client
begins cursing and throwing furniture. The nurse's first action is to: - Correct-
answer-remove all other clients from the day room.
The nurse's first priority is to consider the safety of the clients in the therapeutic
setting. Checking for an as-needed drug order and calling the physician are
appropriate responses after ensuring the safety of other individuals. Because the
client poses a danger to self and others, restraints may be used; however, less
restrictive interventions should be attempted first.
The nurse understands that with the right help at the right time, a client can
successfully resolve a crisis and function better than before the crisis, based
primarily on which factor? - Correct-answer-acquisition of new coping skills
, 4|Page
Learning new coping skills is the major factor necessary for higher functioning.
Better coping is likely to lead to regaining support systems, giving up
dysfunctional coping, and awareness of how to prevent future crises.
A client is admitted for a surgical biopsy of a suspicious lump in the right breast.
At the time the nurse arrives to take the client to surgery, the client is finishing a
letter to the client's children. The client tearfully tells the nurse, "I just want to
leave this for my children in case anything goes wrong in the surgery." Which
nursing response will be most therapeutic? - Correct-answer-What are you
concerned about right now?"
The most therapeutic response is one in which the nurse reflects back to the
client what the client has said and asks the client to reflect further. Making light of
the client's worries about the biopsy does not help the client process their
feelings or concerns. The client did not express questions about the biopsy;
therefore calling the doctor is not appropriate at this time. Confronting the client
about what the nurse feels is misplaced anxiety of the biopsy versus cancer would
not be beneficial to the client and not therapeutic in these circumstances.
Several former clients from a mental health facility have recently collected their
stories to corroborate that a nurse working there has attempted to befriend
them. The clients state that during their therapy, the nurse encouraged them to
invest in a new business. The nursing supervisor, upon hearing of the clients'
reports, begins an investigation. How can the nursing supervisor best describe the
