Exam – 70 Actual Questions with Verified
Clinical Rationales Graded A+
Mental Health Questions (1–70)
1. A nurse is admitting a client with schizophrenia who states, “I’m hearing voices.”
Which response is the nurse’s priority?
o A) “What are the voices saying?”
o B) “Ignore the voices; they aren’t real.”
o C) “I’ll get you medication to stop the voices.”
o D) “You’re safe here; let’s talk about what’s happening.”
o Answer: D. You’re safe here; let’s talk about what’s happening.
o Rationale: Prioritizing safety and establishing trust are critical in managing
hallucinations. This response reassures the client while opening therapeutic
communication, aligning with psychiatric nursing principles.
2. A nurse is caring for a client with depression who states, “I feel like I’m in a dark
hole and can’t get out.” Which response is most therapeutic?
o A) “Everyone feels sad sometimes.”
o B) “Can you describe what that feels like for you?”
o C) “You need to try harder to feel better.”
o D) “That sounds temporary; it’ll pass.”
o Answer: B. Can you describe what that feels like for you?
o Rationale: This response encourages the client to express feelings, fostering
therapeutic communication and assessment of depression severity.
3. A parish nurse is leading a support group for clients whose family members died by
suicide. Which strategy should the nurse use?
o A) Encourage clients to establish a timeline for grieving
o B) Initiate a discussion about coping with family dynamic changes
o C) Assist clients in identifying ways suicide could have been prevented
o D) Discourage sharing negative aspects of their relationship with the deceased
o Answer: B. Initiate a discussion about coping with family dynamic changes
o Rationale: Discussing coping strategies promotes emotional processing and
resilience, supporting group members’ adjustment to loss.
4. A nurse is planning care for an older adult with dementia. Which interventions
should be included? (Select all that apply)
o A) Give one simple direction at a time
o B) Encourage complex decision-making
o C) Maintain a consistent routine
o D) Use physical restraints for safety
, o E) Provide visual cues for orientation
o Answer: A, C, E
o Rationale: Simple directions, consistent routines, and visual cues reduce
confusion and promote safety in dementia care. Restraints are a last resort, and
complex tasks are inappropriate.
5. A nurse is assessing a client with anxiety. Which question helps determine the
severity of anxiety?
o A) “Do you feel anxious all the time?”
o B) “What triggers your anxiety symptoms?”
o C) “Have you ever had a panic attack?”
o D) “Do you enjoy social gatherings?”
o Answer: B. What triggers your anxiety symptoms?
o Rationale: Identifying triggers provides insight into the frequency, intensity, and
context of anxiety, aiding in severity assessment.
6. A nurse is caring for a client who has just started taking lithium. Which assessment
is a priority?
o A) Check for hand tremors
o B) Monitor thyroid function
o C) Assess for suicidal ideation
o D) Evaluate fluid intake and output
o Answer: D. Evaluate fluid intake and output
o Rationale: Lithium has a narrow therapeutic range, and dehydration can lead to
toxicity. Monitoring fluid balance is critical to ensure safety.
7. A client with an eating disorder expresses concern about their weight. What is the
most appropriate nursing intervention?
o A) Encourage the client to avoid weighing themselves
o B) Discuss healthy eating habits in a group setting
o C) Focus on the client’s feelings about their body image
o D) Provide a detailed calorie-counting plan
o Answer: C. Focus on the client’s feelings about their body image
o Rationale: Addressing body image feelings promotes therapeutic exploration of
underlying issues, which is key in eating disorder treatment.
8. A nurse is assessing a client who is experiencing feelings of hopelessness. Which
statement indicates a risk for suicide?
o A) “I wish things were different.”
o B) “I don’t think I can go on living like this.”
o C) “I have a lot of support from my friends.”
o D) “I’m trying to focus on the future.”
o Answer: B. I don’t think I can go on living like this.
o Rationale: This statement expresses despair and potential suicidal ideation,
requiring immediate assessment and intervention.
9. A nurse is providing education on coping strategies to a client with anxiety. Which
strategy is most beneficial?
o A) Avoid all stressful situations
o B) Practice deep breathing exercises
o C) Engage in high-intensity exercise during anxiety