NSG 322/NSG322 Exam 1 V3 | Behavioral
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A client is admitted to the psychiatric unit with a diagnosis of acute mania. Which nursing
intervention is the highest priority according to Maslow’s hierarchy of needs?
A. Ensuring the client remains in their room to prevent agitation
B. Providing high-calorie finger foods and fluids to maintain nutritional status
C. Assisting the client with group therapy participation
D. Discussing the client’s past coping mechanisms
Answer: B
Rationale: In Maslow’s hierarchy, physiological needs take precedence over psychological
or social needs. A client in acute mania is often too hyperactive to sit for meals, putting
them at risk for exhaustion and dehydration. Providing high-calorie finger foods allows the
client to eat while moving, thereby maintaining physical safety and homeostasis.
2. Which ethical principle is being practiced when a nurse honors a client’s decision to refuse
an elective medication?
A. Beneficence
B. Justice
C. Fidelity
,D. Autonomy
Answer: D
Rationale: Autonomy refers to the right of the individual to make their own decisions
regarding their healthcare and treatment. By respecting the client’s refusal, the nurse
acknowledges the client’s self-determination and legal rights. This principle is fundamental
in psychiatric nursing to maintain a collaborative and respectful therapeutic relationship.
3. A nurse is communicating with a client who is experiencing severe anxiety. Which
communication technique is most effective in this situation?
A. Giving broad openings to let the client talk freely
B. Asking ‘why’ the client is feeling so anxious
C. Using short, simple sentences and a calm voice
D. Providing detailed information about the units schedule
Answer: C
Rationale: Clients experiencing severe anxiety have a narrowed perceptual field and
difficulty processing complex information. Short, simple sentences reduce the cognitive
load on the client and help them focus on the nurse’s instructions. Maintaining a calm
demeanor helps prevent the transfer of anxiety from the nurse to the client.
4. During the orientation phase of the nurse-patient relationship, which task should the nurse
focus on primarily?
A. Promoting the client’s insight into their behavior
, B. Identifying the client’s problems and goals
C. Evaluating the progress made toward goals
D. Planning for the client’s discharge and follow-up
Answer: B
Rationale: The orientation phase is characterized by the nurse and client getting to know
each other and establishing a therapeutic contract. During this time, the nurse identifies the
client’s reasons for seeking help and sets mutual goals for the treatment. Establishing trust
and rapport is the foundational work of this phase before moving into the working phase.
5. A client states, ‘I think my family would be better off if I weren’t around anymore.’ Which
response by the nurse is the most therapeutic?
A. ‘Why would you say something so hurtful to yourself?’
B. ‘Are you saying that you are thinking about hurting yourself?’
C. ‘I am sure your family loves you very much.’
D. ‘Let’s talk about something more positive right now.’
Answer: B
Rationale: The nurse’s priority is to assess for suicidal ideation when a client makes a
statement indicating hopelessness or self-harm. Using the technique of seeking clarification
allows the nurse to directly address the safety risk without being judgmental. This
Health Nursing Q&A with Rationale |
Grand Canyon University
1. A client is admitted to the psychiatric unit with a diagnosis of acute mania. Which nursing
intervention is the highest priority according to Maslow’s hierarchy of needs?
A. Ensuring the client remains in their room to prevent agitation
B. Providing high-calorie finger foods and fluids to maintain nutritional status
C. Assisting the client with group therapy participation
D. Discussing the client’s past coping mechanisms
Answer: B
Rationale: In Maslow’s hierarchy, physiological needs take precedence over psychological
or social needs. A client in acute mania is often too hyperactive to sit for meals, putting
them at risk for exhaustion and dehydration. Providing high-calorie finger foods allows the
client to eat while moving, thereby maintaining physical safety and homeostasis.
2. Which ethical principle is being practiced when a nurse honors a client’s decision to refuse
an elective medication?
A. Beneficence
B. Justice
C. Fidelity
,D. Autonomy
Answer: D
Rationale: Autonomy refers to the right of the individual to make their own decisions
regarding their healthcare and treatment. By respecting the client’s refusal, the nurse
acknowledges the client’s self-determination and legal rights. This principle is fundamental
in psychiatric nursing to maintain a collaborative and respectful therapeutic relationship.
3. A nurse is communicating with a client who is experiencing severe anxiety. Which
communication technique is most effective in this situation?
A. Giving broad openings to let the client talk freely
B. Asking ‘why’ the client is feeling so anxious
C. Using short, simple sentences and a calm voice
D. Providing detailed information about the units schedule
Answer: C
Rationale: Clients experiencing severe anxiety have a narrowed perceptual field and
difficulty processing complex information. Short, simple sentences reduce the cognitive
load on the client and help them focus on the nurse’s instructions. Maintaining a calm
demeanor helps prevent the transfer of anxiety from the nurse to the client.
4. During the orientation phase of the nurse-patient relationship, which task should the nurse
focus on primarily?
A. Promoting the client’s insight into their behavior
, B. Identifying the client’s problems and goals
C. Evaluating the progress made toward goals
D. Planning for the client’s discharge and follow-up
Answer: B
Rationale: The orientation phase is characterized by the nurse and client getting to know
each other and establishing a therapeutic contract. During this time, the nurse identifies the
client’s reasons for seeking help and sets mutual goals for the treatment. Establishing trust
and rapport is the foundational work of this phase before moving into the working phase.
5. A client states, ‘I think my family would be better off if I weren’t around anymore.’ Which
response by the nurse is the most therapeutic?
A. ‘Why would you say something so hurtful to yourself?’
B. ‘Are you saying that you are thinking about hurting yourself?’
C. ‘I am sure your family loves you very much.’
D. ‘Let’s talk about something more positive right now.’
Answer: B
Rationale: The nurse’s priority is to assess for suicidal ideation when a client makes a
statement indicating hopelessness or self-harm. Using the technique of seeking clarification
allows the nurse to directly address the safety risk without being judgmental. This
