Mental Health Nursing Exam –
Complete Exam 18 with
Verified Answers (2026
Edition)
Question 1: A client with major depressive disorder is expressing suicidal ideation with a specific plan.
Which action should the nurse take first?
A) Place the client on one-to-one observation
B) Remove all potentially harmful objects from the client's environment
C) Notify the healthcare provider immediately
D) Ask the client about the specifics of the plan
Answer: D) Ask the client about the specifics of the plan
Rationale: When a client expresses suicidal ideation with a specific plan, the nurse must first assess the
specifics of the plan (method, access to means, timing) to determine the level of risk and appropriate
interventions. This assessment is essential for immediate safety planning. The nurse should then remove
harmful objects, initiate one-to-one observation, and notify the healthcare provider. However,
assessment must come first to guide interventions.
Question 2: A client with bipolar disorder is experiencing a manic episode. Which nursing intervention
should the nurse implement?
A) Provide a structured, low-stimulation environment
B) Encourage the client to participate in group activities
C) Allow the client to make all decisions about their care
D) Increase the client's caffeine intake
Answer: A) Provide a structured, low-stimulation environment
Rationale: Clients in a manic episode require a structured, low-stimulation environment to reduce
agitation and promote safety. The nurse should provide a quiet space, limit distractions, and maintain a
calm demeanor. Group activities may overstimulate the client. The client's decision-making may be
impaired, so the nurse should provide appropriate structure and boundaries. Caffeine should be avoided
as it can increase agitation.
,Question 3: A client with schizophrenia is experiencing auditory hallucinations. Which nursing
intervention should the nurse implement?
A) Tell the client that the voices are not real
B) Ask the client about the content of the hallucinations
C) Ignore the client's reports of hallucinations
D) Encourage the client to listen to the voices
Answer: B) Ask the client about the content of the hallucinations
Rationale: When a client experiences auditory hallucinations, the nurse should ask about the content of
the hallucinations (what the voices are saying, if they are commanding, if they are frightening). This
assessment helps determine the client's safety risk and guide interventions. The nurse should not argue
with the client about the reality of the voices or ignore them, as this can increase anxiety. The nurse
should provide a therapeutic presence and redirect the client to reality-based activities.
Question 4: A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. Which
nursing intervention should the nurse implement?
A) Touch the client to ground them in the present
B) Encourage the client to talk about the trauma
C) Speak in a calm, reassuring voice and help the client identify the present
D) Leave the client alone to work through the flashback
Answer: C) Speak in a calm, reassuring voice and help the client identify the present
Rationale: During a flashback, the client is experiencing a trauma response as if the event is occurring in
the present. The nurse should speak in a calm, reassuring voice, orient the client to the present (e.g.,
"You are safe, you are in the hospital, it is 2026"), and use grounding techniques (e.g., focusing on
breathing, physical sensations). The nurse should not touch the client without permission, as touch may
be perceived as threatening. Talking about the trauma can be done later when the client is calm.
Question 5: A client with generalized anxiety disorder (GAD) is experiencing acute anxiety. Which
nursing intervention should the nurse implement?
A) Administer anti-anxiety medication immediately
B) Encourage the client to identify the source of anxiety
C) Provide a quiet environment and use therapeutic communication
D) Leave the client alone to manage the anxiety
Answer: C) Provide a quiet environment and use therapeutic communication
Rationale: During acute anxiety, the nurse should provide a quiet, calm environment and use therapeutic
communication techniques (active listening, open-ended questions, reassurance) to help the client feel
safe and supported. Identifying the source of anxiety can help, but the priority is providing a safe,
, calming environment. Medication may be needed but should not be the first intervention without
assessing the client. Leaving the client alone is not appropriate, as the client may need support to
manage the anxiety.
Question 6: A client with anorexia nervosa is admitted to the hospital. Which nursing intervention
should be prioritized?
A) Encouraging the client to eat independently
B) Monitoring the client's weight and nutritional status
C) Exploring the client's feelings about food and body image
D) Establishing a therapeutic relationship
Answer: B) Monitoring the client's weight and nutritional status
Rationale: For clients with anorexia nervosa, the priority is to stabilize their physical condition and
prevent life-threatening complications (electrolyte imbalances, cardiac arrhythmias, malnutrition). The
nurse should monitor the client's weight, vital signs, and laboratory values closely. While exploring
feelings and establishing a therapeutic relationship are important, they should not take priority over
physiological stabilization. The client may need a structured eating plan with supervision during meals.
Question 7: A client with borderline personality disorder (BPD) is exhibiting self-harming behavior.
Which nursing intervention should the nurse implement?
A) Implement a no-harm contract
B) Monitor the client closely
C) Provide emotional support and validate feelings
D) All of the above
Answer: D) All of the above
Rationale: Clients with BPD who engage in self-harming behavior require a comprehensive approach. The
nurse should implement a no-harm contract (to promote accountability), monitor the client closely (to
ensure safety), and provide emotional support while validating the client's feelings (without reinforcing
the behavior). The nurse should also help the client develop alternative coping strategies and refer the
client for dialectical behavior therapy (DBT), which is the evidence-based treatment for BPD.
Question 8: A client with Alzheimer's disease is experiencing agitation and sundowning. Which nursing
intervention should the nurse implement?
A) Provide a structured daily routine
B) Keep the environment bright and stimulating
C) Encourage daytime napping
D) Restrict fluid intake in the evening
Answer: A) Provide a structured daily routine
Complete Exam 18 with
Verified Answers (2026
Edition)
Question 1: A client with major depressive disorder is expressing suicidal ideation with a specific plan.
Which action should the nurse take first?
A) Place the client on one-to-one observation
B) Remove all potentially harmful objects from the client's environment
C) Notify the healthcare provider immediately
D) Ask the client about the specifics of the plan
Answer: D) Ask the client about the specifics of the plan
Rationale: When a client expresses suicidal ideation with a specific plan, the nurse must first assess the
specifics of the plan (method, access to means, timing) to determine the level of risk and appropriate
interventions. This assessment is essential for immediate safety planning. The nurse should then remove
harmful objects, initiate one-to-one observation, and notify the healthcare provider. However,
assessment must come first to guide interventions.
Question 2: A client with bipolar disorder is experiencing a manic episode. Which nursing intervention
should the nurse implement?
A) Provide a structured, low-stimulation environment
B) Encourage the client to participate in group activities
C) Allow the client to make all decisions about their care
D) Increase the client's caffeine intake
Answer: A) Provide a structured, low-stimulation environment
Rationale: Clients in a manic episode require a structured, low-stimulation environment to reduce
agitation and promote safety. The nurse should provide a quiet space, limit distractions, and maintain a
calm demeanor. Group activities may overstimulate the client. The client's decision-making may be
impaired, so the nurse should provide appropriate structure and boundaries. Caffeine should be avoided
as it can increase agitation.
,Question 3: A client with schizophrenia is experiencing auditory hallucinations. Which nursing
intervention should the nurse implement?
A) Tell the client that the voices are not real
B) Ask the client about the content of the hallucinations
C) Ignore the client's reports of hallucinations
D) Encourage the client to listen to the voices
Answer: B) Ask the client about the content of the hallucinations
Rationale: When a client experiences auditory hallucinations, the nurse should ask about the content of
the hallucinations (what the voices are saying, if they are commanding, if they are frightening). This
assessment helps determine the client's safety risk and guide interventions. The nurse should not argue
with the client about the reality of the voices or ignore them, as this can increase anxiety. The nurse
should provide a therapeutic presence and redirect the client to reality-based activities.
Question 4: A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. Which
nursing intervention should the nurse implement?
A) Touch the client to ground them in the present
B) Encourage the client to talk about the trauma
C) Speak in a calm, reassuring voice and help the client identify the present
D) Leave the client alone to work through the flashback
Answer: C) Speak in a calm, reassuring voice and help the client identify the present
Rationale: During a flashback, the client is experiencing a trauma response as if the event is occurring in
the present. The nurse should speak in a calm, reassuring voice, orient the client to the present (e.g.,
"You are safe, you are in the hospital, it is 2026"), and use grounding techniques (e.g., focusing on
breathing, physical sensations). The nurse should not touch the client without permission, as touch may
be perceived as threatening. Talking about the trauma can be done later when the client is calm.
Question 5: A client with generalized anxiety disorder (GAD) is experiencing acute anxiety. Which
nursing intervention should the nurse implement?
A) Administer anti-anxiety medication immediately
B) Encourage the client to identify the source of anxiety
C) Provide a quiet environment and use therapeutic communication
D) Leave the client alone to manage the anxiety
Answer: C) Provide a quiet environment and use therapeutic communication
Rationale: During acute anxiety, the nurse should provide a quiet, calm environment and use therapeutic
communication techniques (active listening, open-ended questions, reassurance) to help the client feel
safe and supported. Identifying the source of anxiety can help, but the priority is providing a safe,
, calming environment. Medication may be needed but should not be the first intervention without
assessing the client. Leaving the client alone is not appropriate, as the client may need support to
manage the anxiety.
Question 6: A client with anorexia nervosa is admitted to the hospital. Which nursing intervention
should be prioritized?
A) Encouraging the client to eat independently
B) Monitoring the client's weight and nutritional status
C) Exploring the client's feelings about food and body image
D) Establishing a therapeutic relationship
Answer: B) Monitoring the client's weight and nutritional status
Rationale: For clients with anorexia nervosa, the priority is to stabilize their physical condition and
prevent life-threatening complications (electrolyte imbalances, cardiac arrhythmias, malnutrition). The
nurse should monitor the client's weight, vital signs, and laboratory values closely. While exploring
feelings and establishing a therapeutic relationship are important, they should not take priority over
physiological stabilization. The client may need a structured eating plan with supervision during meals.
Question 7: A client with borderline personality disorder (BPD) is exhibiting self-harming behavior.
Which nursing intervention should the nurse implement?
A) Implement a no-harm contract
B) Monitor the client closely
C) Provide emotional support and validate feelings
D) All of the above
Answer: D) All of the above
Rationale: Clients with BPD who engage in self-harming behavior require a comprehensive approach. The
nurse should implement a no-harm contract (to promote accountability), monitor the client closely (to
ensure safety), and provide emotional support while validating the client's feelings (without reinforcing
the behavior). The nurse should also help the client develop alternative coping strategies and refer the
client for dialectical behavior therapy (DBT), which is the evidence-based treatment for BPD.
Question 8: A client with Alzheimer's disease is experiencing agitation and sundowning. Which nursing
intervention should the nurse implement?
A) Provide a structured daily routine
B) Keep the environment bright and stimulating
C) Encourage daytime napping
D) Restrict fluid intake in the evening
Answer: A) Provide a structured daily routine
