NUR 253 Exam 1 V2 | Mental
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client who states, ‘I just can’t take it anymore. My life is over.’ Which
response by the nurse demonstrates therapeutic communication?
A. ‘It sounds like you are feeling very overwhelmed right now. Can you tell me more about
that?’
B. ‘Why do you feel that your life is over?’
C. ‘You shouldn’t say that. You have so much to live for.’
D. ‘I understand how you feel. I’ve had bad days too.’
Correct Answer: A
Expert Explanation: This response uses the therapeutic technique of reflection and
offering an open-ended lead. It encourages the client to explore their feelings without being
judgmental or dismissive. Avoid using ‘why’ questions as they can cause the client to
become defensive and shut down communication.
2. According to Maslow’s Hierarchy of Needs, which of the following should the nurse
prioritize first for a newly admitted client?
A. Ensuring the client has adequate food, water, and sleep.
B. Encouraging the client to participate in group social activities.
,C. Assessing the client’s self-esteem and confidence.
D. Providing a safe and secure environment for the client.
Correct Answer: A
Expert Explanation: Maslow’s hierarchy dictates that basic physiological needs must be
met before higher-level needs like safety or belonging. These needs include air, water, food,
shelter, sleep, and clothing. Once these fundamental requirements are addressed, the nurse
can then focus on safety and psychological aspects of care.
3. A nurse is providing care for a client who has been involuntarily committed to a mental
health facility. Which of the following rights does the client still retain?
A. The right to refuse psychotropic medications.
B. The right to leave the facility against medical advice at any time.
C. The right to possess dangerous items in their room.
D. The right to avoid all scheduled therapy sessions.
Correct Answer: A
Expert Explanation: Clients who are involuntarily committed still maintain the right to
refuse treatment, including medications, unless they are a danger to themselves or others.
Involuntary admission only restricts their right to leave the facility freely. The legal process
for forced medication usually involves a separate court hearing or emergency protocols.
, 4. During a clinical interview, a client becomes angry and threatens to harm their neighbor.
What is the nurse’s legal obligation in this situation?
A. Keep the information confidential as part of the nurse-client relationship.
B. Wait until the client is discharged to notify the proper authorities.
C. Report the threat to the treatment team and ensure the intended victim is warned.
D. Document the threat but take no further action until the client acts on it.
Correct Answer: C
Expert Explanation: This refers to the ‘Duty to Warn’ or Tarasoff ruling, which mandates
that mental health professionals notify potential victims and authorities of specific threats.
Safety takes precedence over patient confidentiality in cases of clear and present danger to
others. Failure to report such threats can lead to legal liability for the healthcare provider.
5. A nurse is in the orientation phase of the therapeutic relationship with a client. Which of
the following actions should the nurse perform?
A. Evaluate the progress made toward the client’s goals.
B. Assist the client in developing problem-solving skills.
C. Establish the parameters of the relationship and set goals with the client.
D. Discuss the client’s feelings regarding the upcoming termination of the relationship.
Correct Answer: C
Health Nursing Q&A with Rationale
| Galen College of Nursing
1. A nurse is caring for a client who states, ‘I just can’t take it anymore. My life is over.’ Which
response by the nurse demonstrates therapeutic communication?
A. ‘It sounds like you are feeling very overwhelmed right now. Can you tell me more about
that?’
B. ‘Why do you feel that your life is over?’
C. ‘You shouldn’t say that. You have so much to live for.’
D. ‘I understand how you feel. I’ve had bad days too.’
Correct Answer: A
Expert Explanation: This response uses the therapeutic technique of reflection and
offering an open-ended lead. It encourages the client to explore their feelings without being
judgmental or dismissive. Avoid using ‘why’ questions as they can cause the client to
become defensive and shut down communication.
2. According to Maslow’s Hierarchy of Needs, which of the following should the nurse
prioritize first for a newly admitted client?
A. Ensuring the client has adequate food, water, and sleep.
B. Encouraging the client to participate in group social activities.
,C. Assessing the client’s self-esteem and confidence.
D. Providing a safe and secure environment for the client.
Correct Answer: A
Expert Explanation: Maslow’s hierarchy dictates that basic physiological needs must be
met before higher-level needs like safety or belonging. These needs include air, water, food,
shelter, sleep, and clothing. Once these fundamental requirements are addressed, the nurse
can then focus on safety and psychological aspects of care.
3. A nurse is providing care for a client who has been involuntarily committed to a mental
health facility. Which of the following rights does the client still retain?
A. The right to refuse psychotropic medications.
B. The right to leave the facility against medical advice at any time.
C. The right to possess dangerous items in their room.
D. The right to avoid all scheduled therapy sessions.
Correct Answer: A
Expert Explanation: Clients who are involuntarily committed still maintain the right to
refuse treatment, including medications, unless they are a danger to themselves or others.
Involuntary admission only restricts their right to leave the facility freely. The legal process
for forced medication usually involves a separate court hearing or emergency protocols.
, 4. During a clinical interview, a client becomes angry and threatens to harm their neighbor.
What is the nurse’s legal obligation in this situation?
A. Keep the information confidential as part of the nurse-client relationship.
B. Wait until the client is discharged to notify the proper authorities.
C. Report the threat to the treatment team and ensure the intended victim is warned.
D. Document the threat but take no further action until the client acts on it.
Correct Answer: C
Expert Explanation: This refers to the ‘Duty to Warn’ or Tarasoff ruling, which mandates
that mental health professionals notify potential victims and authorities of specific threats.
Safety takes precedence over patient confidentiality in cases of clear and present danger to
others. Failure to report such threats can lead to legal liability for the healthcare provider.
5. A nurse is in the orientation phase of the therapeutic relationship with a client. Which of
the following actions should the nurse perform?
A. Evaluate the progress made toward the client’s goals.
B. Assist the client in developing problem-solving skills.
C. Establish the parameters of the relationship and set goals with the client.
D. Discuss the client’s feelings regarding the upcoming termination of the relationship.
Correct Answer: C
