Grade A+ NCLEX Style Questions and Rationales for Nursing Practice 2025
Nurse's best initial action for a client Sit near the client and calmly ask what
rocking back and forth he's experiencing.
Action that promotes client's autonomy Allowing the client to make decisions
in therapeutic relationship within agreed limits.
Nurse's response demonstrating empa- Tell me more about what makes you feel
thy to a client feeling misunderstood that way.
Client behavior requiring pause in dis- The client refuses prescribed medica-
charge planning tions and isolates in their room.
Finding indicating disturbance in senso- The client cannot recall the day of the
rium and cognition week or current location.
Nurse's priority action for a client ex- Assess for suicidal ideation and safety
pressing worthlessness risk.
Behavior indicating progress in recovery Beginning to bathe and dress with mini-
from a psychotic episode mal prompting.
Assessing for harm Always the nurse's first priority.
Physiological; hygiene is a basic physical
Maslow's need being met
need.
Exploring triggers is especially appropri-
Therapeutic communication in crisis
ate in crisis intervention.
Allowing the client to choose when to
Accepting the client as a whole person
attend based on readiness.
Inviting the client to clarify and share
Promoting trust with clients
more promotes trust.
Ask the client directly, 'Are you hearing
Nursing action for schizophrenia
something right now?'
Stand and maintain a safe distance while
First action when client is agitated
offering support.
Acknowledging the client's feelings of
Response using acceptance principle
failure.
A technique that validates the client's
Therapeutic Listening emotion without judgment, demonstrat-
ing acceptance.
1/3
Nurse's best initial action for a client Sit near the client and calmly ask what
rocking back and forth he's experiencing.
Action that promotes client's autonomy Allowing the client to make decisions
in therapeutic relationship within agreed limits.
Nurse's response demonstrating empa- Tell me more about what makes you feel
thy to a client feeling misunderstood that way.
Client behavior requiring pause in dis- The client refuses prescribed medica-
charge planning tions and isolates in their room.
Finding indicating disturbance in senso- The client cannot recall the day of the
rium and cognition week or current location.
Nurse's priority action for a client ex- Assess for suicidal ideation and safety
pressing worthlessness risk.
Behavior indicating progress in recovery Beginning to bathe and dress with mini-
from a psychotic episode mal prompting.
Assessing for harm Always the nurse's first priority.
Physiological; hygiene is a basic physical
Maslow's need being met
need.
Exploring triggers is especially appropri-
Therapeutic communication in crisis
ate in crisis intervention.
Allowing the client to choose when to
Accepting the client as a whole person
attend based on readiness.
Inviting the client to clarify and share
Promoting trust with clients
more promotes trust.
Ask the client directly, 'Are you hearing
Nursing action for schizophrenia
something right now?'
Stand and maintain a safe distance while
First action when client is agitated
offering support.
Acknowledging the client's feelings of
Response using acceptance principle
failure.
A technique that validates the client's
Therapeutic Listening emotion without judgment, demonstrat-
ing acceptance.
1/3
