Q&A | Mental Health Nursing
1. A nurse educator is presenting information about the nursing process to a
class of nursing students. What definition of the nursing process should be
included in the presentation?
A) Procedures used to implement client care
B) Sequence of steps used to meet the client's needs
C) Activities employed to identify a client's problem
D) Mechanisms applied to determine nursing goals for the client
Correct Answer: Sequence of steps used to meet the client's needs
Rationale: The nursing process is a systematic, client-centered method for
structuring the delivery of nursing care. It is best described as a sequence of
steps (Assessment, Diagnosis, Planning, Implementation, Evaluation) used to
meet the client's needs, not just to identify problems or determine goals in
isolation.
2. A nurse has performed pre-operative care on a client and is transferring
the client to the surgical holding area when the client states, "I have changed
my mind; I do not want to have this surgery." Which of the following ethical
principles is the client exercising?
A) Nonmaleficence
B) Autonomy
C) Justice
D) Fidelity
Correct Answer: Autonomy
,Rationale: Autonomy is the client's right to make independent decisions
about their own healthcare, including refusing treatment or surgery. Here,
the client is exercising control over their own body and care plan.
Nonmaleficence relates to avoiding harm, justice refers to fairness, and
fidelity involves keeping promises.
3. Which defense mechanism is a client using when they state, "I'm not
angry at my boss at all. My co-workers are just too sensitive"?
A) Projection
B) Rationalization
C) Displacement
D) Reaction formation
Correct Answer: Displacement
Rationale: Displacement involves transferring an emotion (anger) from the
original source (the boss) to a safer target (co-workers). Projection would be
accusing the boss of being angry, and reaction formation would be acting
overly nice to the boss.
4. A nurse is preparing to assess a newly admitted client. Which of the
following pieces of equipment does the nurse need to begin the inspection
part of the physical examination?
A) Electrocardiogram monitor
B) Tongue depressor
C) Penlight
D) Stethoscope
Correct Answer: Penlight
,Rationale: Inspection is the first and most basic technique of physical
assessment, and it requires only good lighting and sometimes a penlight for
examining areas like the eyes, mouth, or throat. A stethoscope is for
auscultation, and a tongue depressor is for examining the mouth and throat.
5. A client tells the nurse, "I feel like nobody cares if I live or die." Which
response is the best example of the therapeutic technique of "reflection"?
A) "You feel that nobody cares about you?"
B) "Why do you think you feel that people don't care?"
C) "Nobody cares?"
D) "Let's focus on your family; they care about you."
Correct Answer: "Nobody cares?"
Rationale: Reflection involves repeating the client's exact words or a key
phrase to encourage elaboration. Option A is paraphrasing, option B uses
"why," which can sound accusatory, and option D changes the subject.
6. According to Peplau's Interpersonal Relations Theory, during which phase
does the patient begin to identify problems to work on and explore feelings?
A) Orientation phase
B) Working phase
C) Termination phase
D) Pre-orientation phase
Correct Answer: Working phase
Rationale: In the working phase, the patient actively explores problems,
identifies issues, and works toward change. The orientation phase is for
, trust-building and setting expectations, while the termination phase is for
ending the relationship.
7. A nurse is caring for a client who is using the defense mechanism of
denial. Which statement by the client is most consistent with this
mechanism?
A) "I only drink a little bit on the weekends. It's not a problem."
B) "I didn't get the job because the interviewer was biased against me."
C) "I'm not angry; I'm just disappointed."
D) "I can't remember anything about that day."
Correct Answer: "I only drink a little bit on the weekends. It's not a problem."
Rationale: Denial is the refusal to acknowledge the reality of a situation or
the existence of a problem. By stating their drinking is not a problem, the
patient is actively denying the reality of their alcohol use disorder.
8. A nurse is establishing a therapeutic relationship with a client. Which
action is most important for maintaining professional boundaries?
A) Sharing personal experiences to build rapport
B) Accepting gifts from the client
C) Avoiding self-disclosure that does not benefit the client
D) Meeting the client outside of the healthcare setting
Correct Answer: Avoiding self-disclosure that does not benefit the client
Rationale: Self-disclosure should be used sparingly and only when it is clearly
beneficial to the client. Sharing personal information for the nurse's own
needs or to build rapport can blur professional boundaries.