Rasmussen Mental Health Exam 2 – Latest Version (Updated
2024) with Complete Solution
Question 1:
A nurse is caring for a client with major depressive disorder who states, “I don’t have any reason
to live anymore.” Which of the following is the nurse’s priority response?
A) "Have you thought about hurting yourself?"
B) "You have so much to live for, don’t say that."
C) "Why do you feel that way?"
D) "Let’s focus on some positive things in your life."
Correct Answer: A
Rationale: Asking directly about suicidal ideation (A) is the priority to assess immediate safety
risk, as per therapeutic communication principles in psychiatric nursing. Response B minimizes
the client’s feelings and invalidates their experience. Option C may evoke defensiveness without
addressing safety. D redirects away from the critical issue, delaying risk assessment.
Question 2:
During a psychiatric assessment, a client with anxiety disorder exhibits rapid speech,
restlessness, and diaphoresis. Which therapeutic communication technique should the nurse
use first?
A) Reassurance
B) Reflection
C) Giving advice
D) Silence
Correct Answer: B
Rationale: Reflection (B) validates the client’s feelings and encourages elaboration, promoting
trust and accurate assessment in anxiety disorders. Reassurance (A) may dismiss symptoms.
Giving advice (C) is directive and non-therapeutic early. Silence (D) can increase anxiety without
guidance.
Question 3:
A nurse is interviewing a client admitted for schizophrenia. The client reports hearing voices
telling them to harm others. What is the priority nursing action?
A) Administer an antipsychotic medication immediately.
B) Assess the client's intent and means to act on the voices.
C) Place the client in seclusion.
,D) Notify the physician for a medication change.
Correct Answer: B
Rationale: Assessing intent and lethality (B) is priority to ensure safety in psychotic disorders, as
per assessment guidelines. Medication (A) follows evaluation. Seclusion (C) is last resort.
Physician notification (D) is secondary to immediate risk assessment.
Question 4:
A client with generalized anxiety disorder asks the nurse, “What if I fail my exam next week?”
Which response demonstrates active listening?
A) "Everyone gets anxious about exams; it will pass."
B) "Tell me more about what failing means to you."
C) "You should study more to avoid that."
D) "Don't worry; you'll do fine."
Correct Answer: B
Rationale: Active listening via open-ended questioning (B) encourages the client to explore
feelings, key in anxiety management. A dismisses concerns. C is judgmental. D minimizes
anxiety.
Question 5:
A nurse observes a client with bipolar disorder pacing and speaking loudly during a manic
episode. Which intervention is most appropriate?
A) Administer a benzodiazepine PRN.
B) Encourage the client to sit and discuss feelings.
C) Restrain the client to prevent injury.
D) Ignore the behavior as it is typical.
Correct Answer: B
Rationale: De-escalation through engagement (B) reduces agitation in mania, promoting
therapeutic rapport. Benzodiazepine (A) if escalating. Restraint (C) is restrictive. Ignoring (D)
misses intervention opportunity.
Question 6:
In assessing a client with obsessive-compulsive disorder, the nurse notes the client performs
rituals for 2 hours daily. Which statement best reflects therapeutic communication?
A) "Your rituals seem unnecessary; try to stop."
B) "How do you feel when you can't complete a ritual?"
C) "Rituals are common; no need to change."
D) "I had a similar habit once; it goes away."
,Correct Answer: B
Rationale: Exploring feelings (B) builds insight into OCD compulsions without judgment. A is
confrontational. C invalidates need for treatment. D shifts focus to nurse.
Question 7:
A client with post-traumatic stress disorder (PTSD) relives a trauma during a therapy session,
becoming tearful. The nurse's best response is:
A) "It's okay to cry; this is part of healing."
B) "Let's change the subject to something positive."
C) "You need to toughen up and move on."
D) "Tell me exactly what happened again."
Correct Answer: A
Rationale: Validation and support (A) facilitate emotional processing in PTSD. Changing subject
(B) avoids trauma. C is dismissive. Repeating (D) may retraumatize without support.
Question 8:
During a mental status exam, a client with depression shows psychomotor retardation and flat
affect. Which additional finding would confirm major depressive disorder?
A) Grandiose delusions
B) Anhedonia and sleep disturbance
C) Flight of ideas
D) Echolalia
Correct Answer: B
Rationale: Anhedonia and sleep changes (B) are core DSM-5 criteria for MDD. Grandiosity (A)
and flight of ideas (C) indicate mania. Echolalia (D) is schizophrenia-related.
Question 9:
A nurse is using the mental status examination to assess orientation. A client correctly identifies
the date and place but not the president. This indicates impairment in:
A) Time orientation only
B) Person orientation
C) Recent memory
D) Remote memory
Correct Answer: C
, Rationale: Difficulty with current events (president) suggests recent memory impairment (C),
common in delirium or dementia. Time (A) partial. Person (B) self-awareness. Remote (D) past
events.
Question 10:
A client with schizophrenia whispers to the nurse, "The voices say you're poisoning my food."
The nurse's therapeutic response is:
A) "I hear you saying the voices are telling you that; can you tell me more?"
B) "The voices aren't real; you need medication."
C) "That's not true; I would never do that."
D) "Let's ignore the voices and talk about lunch."
Correct Answer: A
Rationale: Acknowledging the hallucination without reinforcing (A) builds trust and assesses
content. Denying (B, C) increases isolation. Ignoring (D) dismisses experience.
Question 11:
A client with panic disorder hyperventilates during an attack. The nurse teaches breathing
techniques. Which statement indicates understanding?
A) "I'll breathe into a paper bag to increase CO2."
B) "I'll hold my breath to stop the attack."
C) "Deep breathing will make me pass out."
D) "I should run to burn off anxiety."
Correct Answer: A
Rationale: Rebreathing CO2 (A) counters respiratory alkalosis in panic. Holding breath (B)
worsens. Deep breathing (C) correct but fear invalid. Running (D) avoidance.
Question 12:
A nurse is planning care for a client with social anxiety disorder. Which intervention promotes
coping?
A) Encourage isolation to avoid triggers.
B) Role-play social interactions in therapy.
C) Prescribe avoidance medication.
D) Limit all group activities.
Correct Answer: B
Rationale: Exposure therapy via role-play (B) desensitizes anxiety, evidence-based for SAD.
Isolation (A, D) reinforces. Medication (C) adjunct, not coping.
2024) with Complete Solution
Question 1:
A nurse is caring for a client with major depressive disorder who states, “I don’t have any reason
to live anymore.” Which of the following is the nurse’s priority response?
A) "Have you thought about hurting yourself?"
B) "You have so much to live for, don’t say that."
C) "Why do you feel that way?"
D) "Let’s focus on some positive things in your life."
Correct Answer: A
Rationale: Asking directly about suicidal ideation (A) is the priority to assess immediate safety
risk, as per therapeutic communication principles in psychiatric nursing. Response B minimizes
the client’s feelings and invalidates their experience. Option C may evoke defensiveness without
addressing safety. D redirects away from the critical issue, delaying risk assessment.
Question 2:
During a psychiatric assessment, a client with anxiety disorder exhibits rapid speech,
restlessness, and diaphoresis. Which therapeutic communication technique should the nurse
use first?
A) Reassurance
B) Reflection
C) Giving advice
D) Silence
Correct Answer: B
Rationale: Reflection (B) validates the client’s feelings and encourages elaboration, promoting
trust and accurate assessment in anxiety disorders. Reassurance (A) may dismiss symptoms.
Giving advice (C) is directive and non-therapeutic early. Silence (D) can increase anxiety without
guidance.
Question 3:
A nurse is interviewing a client admitted for schizophrenia. The client reports hearing voices
telling them to harm others. What is the priority nursing action?
A) Administer an antipsychotic medication immediately.
B) Assess the client's intent and means to act on the voices.
C) Place the client in seclusion.
,D) Notify the physician for a medication change.
Correct Answer: B
Rationale: Assessing intent and lethality (B) is priority to ensure safety in psychotic disorders, as
per assessment guidelines. Medication (A) follows evaluation. Seclusion (C) is last resort.
Physician notification (D) is secondary to immediate risk assessment.
Question 4:
A client with generalized anxiety disorder asks the nurse, “What if I fail my exam next week?”
Which response demonstrates active listening?
A) "Everyone gets anxious about exams; it will pass."
B) "Tell me more about what failing means to you."
C) "You should study more to avoid that."
D) "Don't worry; you'll do fine."
Correct Answer: B
Rationale: Active listening via open-ended questioning (B) encourages the client to explore
feelings, key in anxiety management. A dismisses concerns. C is judgmental. D minimizes
anxiety.
Question 5:
A nurse observes a client with bipolar disorder pacing and speaking loudly during a manic
episode. Which intervention is most appropriate?
A) Administer a benzodiazepine PRN.
B) Encourage the client to sit and discuss feelings.
C) Restrain the client to prevent injury.
D) Ignore the behavior as it is typical.
Correct Answer: B
Rationale: De-escalation through engagement (B) reduces agitation in mania, promoting
therapeutic rapport. Benzodiazepine (A) if escalating. Restraint (C) is restrictive. Ignoring (D)
misses intervention opportunity.
Question 6:
In assessing a client with obsessive-compulsive disorder, the nurse notes the client performs
rituals for 2 hours daily. Which statement best reflects therapeutic communication?
A) "Your rituals seem unnecessary; try to stop."
B) "How do you feel when you can't complete a ritual?"
C) "Rituals are common; no need to change."
D) "I had a similar habit once; it goes away."
,Correct Answer: B
Rationale: Exploring feelings (B) builds insight into OCD compulsions without judgment. A is
confrontational. C invalidates need for treatment. D shifts focus to nurse.
Question 7:
A client with post-traumatic stress disorder (PTSD) relives a trauma during a therapy session,
becoming tearful. The nurse's best response is:
A) "It's okay to cry; this is part of healing."
B) "Let's change the subject to something positive."
C) "You need to toughen up and move on."
D) "Tell me exactly what happened again."
Correct Answer: A
Rationale: Validation and support (A) facilitate emotional processing in PTSD. Changing subject
(B) avoids trauma. C is dismissive. Repeating (D) may retraumatize without support.
Question 8:
During a mental status exam, a client with depression shows psychomotor retardation and flat
affect. Which additional finding would confirm major depressive disorder?
A) Grandiose delusions
B) Anhedonia and sleep disturbance
C) Flight of ideas
D) Echolalia
Correct Answer: B
Rationale: Anhedonia and sleep changes (B) are core DSM-5 criteria for MDD. Grandiosity (A)
and flight of ideas (C) indicate mania. Echolalia (D) is schizophrenia-related.
Question 9:
A nurse is using the mental status examination to assess orientation. A client correctly identifies
the date and place but not the president. This indicates impairment in:
A) Time orientation only
B) Person orientation
C) Recent memory
D) Remote memory
Correct Answer: C
, Rationale: Difficulty with current events (president) suggests recent memory impairment (C),
common in delirium or dementia. Time (A) partial. Person (B) self-awareness. Remote (D) past
events.
Question 10:
A client with schizophrenia whispers to the nurse, "The voices say you're poisoning my food."
The nurse's therapeutic response is:
A) "I hear you saying the voices are telling you that; can you tell me more?"
B) "The voices aren't real; you need medication."
C) "That's not true; I would never do that."
D) "Let's ignore the voices and talk about lunch."
Correct Answer: A
Rationale: Acknowledging the hallucination without reinforcing (A) builds trust and assesses
content. Denying (B, C) increases isolation. Ignoring (D) dismisses experience.
Question 11:
A client with panic disorder hyperventilates during an attack. The nurse teaches breathing
techniques. Which statement indicates understanding?
A) "I'll breathe into a paper bag to increase CO2."
B) "I'll hold my breath to stop the attack."
C) "Deep breathing will make me pass out."
D) "I should run to burn off anxiety."
Correct Answer: A
Rationale: Rebreathing CO2 (A) counters respiratory alkalosis in panic. Holding breath (B)
worsens. Deep breathing (C) correct but fear invalid. Running (D) avoidance.
Question 12:
A nurse is planning care for a client with social anxiety disorder. Which intervention promotes
coping?
A) Encourage isolation to avoid triggers.
B) Role-play social interactions in therapy.
C) Prescribe avoidance medication.
D) Limit all group activities.
Correct Answer: B
Rationale: Exposure therapy via role-play (B) desensitizes anxiety, evidence-based for SAD.
Isolation (A, D) reinforces. Medication (C) adjunct, not coping.
