NUR 256 Exam 1 V1 | NUR 256 Concepts of Mental
Health Nursing | Q&A with Rationale (NUR256
Exam 1) | Galen College of Nursing
1. A nurse is caring for a client who threatens to harm their roommate. According to the
Tarasoff ruling, which action must the nurse take?
A. Inform the treatment team so the intended victim can be notified.
B. Maintain client confidentiality and document the threat in the chart.
C. Place the client in immediate physical restraints for safety.
D. Administer a PRN sedative to reduce the client’s aggression.
Correct Answer: A
Explanation: The Tarasoff ruling established the ‘duty to warn’ when a client makes a
specific threat against an identifiable individual. The nurse’s primary responsibility is to
ensure the safety of others by reporting the threat to the provider and treatment team. This
legal obligation supersedes standard patient confidentiality protocols in the interest of
public safety.
2. Which phase of the nurse-patient relationship involves establishing boundaries and a
contract for meeting?
A. Orientation phase
B. Pre-interaction phase
,C. Working phase
D. Termination phase
Correct Answer: A
Explanation: The orientation phase is the initial meeting where the nurse and client define
the purpose and boundaries of the relationship. During this time, the nurse establishes
trust and identifies the client’s expectations for treatment. Setting a contract for the
frequency and duration of meetings is a key task of this specific stage.
3. A client states, ‘I don’t think I can handle this anymore.’ The nurse responds, ‘You feel
overwhelmed with your current situation?’ Which technique is the nurse using?
A. Reflecting
B. Exploring
C. Restating
D. Summarizing
Correct Answer: A
Explanation: Reflecting involves directing back the client’s feelings or ideas so they can be
recognized and accepted. This technique helps the client understand their own emotions
better by hearing them articulated by the nurse. It encourages the client to continue
expressing their inner feelings in a safe environment.
, 4. According to Erikson’s stages of psychosocial development, which task is primary for a
middle-aged adult?
A. Autonomy vs. Shame and Doubt
B. Generativity vs. Stagnation
C. Identity vs. Role Confusion
D. Integrity vs. Despair
Correct Answer: B
Explanation: Middle adulthood is characterized by the conflict of Generativity versus
Stagnation, focusing on contributing to the next generation. Success in this stage leads to
feelings of usefulness and accomplishment, while failure results in shallow involvement in
the world. The nurse assesses if the client is finding ways to support others or feels stuck in
their own development.
5. Which level of anxiety is characterized by a narrowed perceptual field and the ability to
focus on only one detail?
A. Severe anxiety
B. Moderate anxiety
C. Mild anxiety
D. Panic level anxiety
Correct Answer: A
Health Nursing | Q&A with Rationale (NUR256
Exam 1) | Galen College of Nursing
1. A nurse is caring for a client who threatens to harm their roommate. According to the
Tarasoff ruling, which action must the nurse take?
A. Inform the treatment team so the intended victim can be notified.
B. Maintain client confidentiality and document the threat in the chart.
C. Place the client in immediate physical restraints for safety.
D. Administer a PRN sedative to reduce the client’s aggression.
Correct Answer: A
Explanation: The Tarasoff ruling established the ‘duty to warn’ when a client makes a
specific threat against an identifiable individual. The nurse’s primary responsibility is to
ensure the safety of others by reporting the threat to the provider and treatment team. This
legal obligation supersedes standard patient confidentiality protocols in the interest of
public safety.
2. Which phase of the nurse-patient relationship involves establishing boundaries and a
contract for meeting?
A. Orientation phase
B. Pre-interaction phase
,C. Working phase
D. Termination phase
Correct Answer: A
Explanation: The orientation phase is the initial meeting where the nurse and client define
the purpose and boundaries of the relationship. During this time, the nurse establishes
trust and identifies the client’s expectations for treatment. Setting a contract for the
frequency and duration of meetings is a key task of this specific stage.
3. A client states, ‘I don’t think I can handle this anymore.’ The nurse responds, ‘You feel
overwhelmed with your current situation?’ Which technique is the nurse using?
A. Reflecting
B. Exploring
C. Restating
D. Summarizing
Correct Answer: A
Explanation: Reflecting involves directing back the client’s feelings or ideas so they can be
recognized and accepted. This technique helps the client understand their own emotions
better by hearing them articulated by the nurse. It encourages the client to continue
expressing their inner feelings in a safe environment.
, 4. According to Erikson’s stages of psychosocial development, which task is primary for a
middle-aged adult?
A. Autonomy vs. Shame and Doubt
B. Generativity vs. Stagnation
C. Identity vs. Role Confusion
D. Integrity vs. Despair
Correct Answer: B
Explanation: Middle adulthood is characterized by the conflict of Generativity versus
Stagnation, focusing on contributing to the next generation. Success in this stage leads to
feelings of usefulness and accomplishment, while failure results in shallow involvement in
the world. The nurse assesses if the client is finding ways to support others or feels stuck in
their own development.
5. Which level of anxiety is characterized by a narrowed perceptual field and the ability to
focus on only one detail?
A. Severe anxiety
B. Moderate anxiety
C. Mild anxiety
D. Panic level anxiety
Correct Answer: A
