HESI COMPASS MODULE EXAM 4 EXAM
PREP 2026 PRIORITIZATION DELEGATION
AND OUTCOME EVALUATION COMPLETE
SOLUTIONS
◉ A psychiatric nurse is playing a card game with a client in the day
room. The client states to the nurse, "The voice in my head is telling
me that you're cheating." Which of the following responses by the
nurse is therapeutic?
Answer: "I do not hear any voices. Has the voice said anything else?"
Rationale: When caring for a client experiencing delusions or
hallucinations, the nurse should listen to the client, present reality,
and collect more data regarding the content of the delusion and/or
hallucination. Stating, "I do not hear any voices. Has the voice said
anything else?" is correct because it presents reality and collects
more data from the client. Although stating, "Is the voice telling you
to do anything?" collects more data, it does not present reality.
Stating, "It isn't possible for people to hear voices in their head" and
"I don't believe that you are hearing voices" are non-therapeutic and
do not address the needs or feelings of the client.
◉ A client says to the nurse, "I'm really phobic about flying, so my
husband and I always drove or took the train everywhere. Now he's
,been offered a big job in Europe, and if I don't get over this and fly
with him, he says we're done. I'll be left to bring up our three
children by myself." Which statement by the nurse would be
therapeutic?
Answer: "I can teach you strategies to help master your panic. An
antianxiety medicine would also help you."
Rationale: A phobia is a persistent, irrational fear of a specific object,
activity, or situation that leads to a desire for avoidance or actual
avoidance of the object, activity, or situation. The nurse can teach
strategies, such as relaxation training and thought-stopping, to help
the client master her anxiety. There are also medications that the
psychiatrist can prescribe to help ease the client's phobia. In stating,
"No problem. You can be hypnotized to sleep through your trip," the
nurse provides false reassurance and belittles the client's worries
and fears. In responding, "I'm interested that it took his threat of
leaving you to motivate you to seek help," the nurse uses a
nontherapeutic change of subject that can only increase the client's
anxiety and fear. This response also lowers the client's trust in her
relationship with the nurse. In stating, "You seem more anxious and
afraid of raising three children alone than of flying," the nurse
changes the subject.
◉ A nurse is trying to deescalate aggressive behavior exhibited by a
client with schizophrenia. Which nursing action would be
contraindicated in this situation?
, Answer: Standing close to the client and telling the client that the
behavior is unacceptable
Rationale: To deescalate aggressive behavior, the nurse should
maintain calm and a nonaggressive posture. The nurse should also
give the client clear instructions that are brief and assertive and
negotiate options with the client. Negotiation of options allows the
client to feel that he or she has some room in making decisions. The
nurse needs to maintain personal space and should not stand closer
than about 8 feet from the client, which would convey a threatening
message.
◉ A client is scheduled to undergo electroconvulsive therapy (ECT).
Which client concern is of the highest priority?
g
Answer: Risk for impaired breathing
Rationale: NPO status for 6 to 8 hours before a procedure, removal
of dentures during the procedure, and administration of medication
as prescribed to diminish oral secretions are all safeguards against
aspiration during ECT. Although fear and anxiety could also be
concerns, they are not the most important ones. There is no reason
to infer that distorted body image is a consideration.
◉ The mother of a child who is taking methylphenidate
hydrochloride (Ritalin) tells the school nurse that she is
PREP 2026 PRIORITIZATION DELEGATION
AND OUTCOME EVALUATION COMPLETE
SOLUTIONS
◉ A psychiatric nurse is playing a card game with a client in the day
room. The client states to the nurse, "The voice in my head is telling
me that you're cheating." Which of the following responses by the
nurse is therapeutic?
Answer: "I do not hear any voices. Has the voice said anything else?"
Rationale: When caring for a client experiencing delusions or
hallucinations, the nurse should listen to the client, present reality,
and collect more data regarding the content of the delusion and/or
hallucination. Stating, "I do not hear any voices. Has the voice said
anything else?" is correct because it presents reality and collects
more data from the client. Although stating, "Is the voice telling you
to do anything?" collects more data, it does not present reality.
Stating, "It isn't possible for people to hear voices in their head" and
"I don't believe that you are hearing voices" are non-therapeutic and
do not address the needs or feelings of the client.
◉ A client says to the nurse, "I'm really phobic about flying, so my
husband and I always drove or took the train everywhere. Now he's
,been offered a big job in Europe, and if I don't get over this and fly
with him, he says we're done. I'll be left to bring up our three
children by myself." Which statement by the nurse would be
therapeutic?
Answer: "I can teach you strategies to help master your panic. An
antianxiety medicine would also help you."
Rationale: A phobia is a persistent, irrational fear of a specific object,
activity, or situation that leads to a desire for avoidance or actual
avoidance of the object, activity, or situation. The nurse can teach
strategies, such as relaxation training and thought-stopping, to help
the client master her anxiety. There are also medications that the
psychiatrist can prescribe to help ease the client's phobia. In stating,
"No problem. You can be hypnotized to sleep through your trip," the
nurse provides false reassurance and belittles the client's worries
and fears. In responding, "I'm interested that it took his threat of
leaving you to motivate you to seek help," the nurse uses a
nontherapeutic change of subject that can only increase the client's
anxiety and fear. This response also lowers the client's trust in her
relationship with the nurse. In stating, "You seem more anxious and
afraid of raising three children alone than of flying," the nurse
changes the subject.
◉ A nurse is trying to deescalate aggressive behavior exhibited by a
client with schizophrenia. Which nursing action would be
contraindicated in this situation?
, Answer: Standing close to the client and telling the client that the
behavior is unacceptable
Rationale: To deescalate aggressive behavior, the nurse should
maintain calm and a nonaggressive posture. The nurse should also
give the client clear instructions that are brief and assertive and
negotiate options with the client. Negotiation of options allows the
client to feel that he or she has some room in making decisions. The
nurse needs to maintain personal space and should not stand closer
than about 8 feet from the client, which would convey a threatening
message.
◉ A client is scheduled to undergo electroconvulsive therapy (ECT).
Which client concern is of the highest priority?
g
Answer: Risk for impaired breathing
Rationale: NPO status for 6 to 8 hours before a procedure, removal
of dentures during the procedure, and administration of medication
as prescribed to diminish oral secretions are all safeguards against
aspiration during ECT. Although fear and anxiety could also be
concerns, they are not the most important ones. There is no reason
to infer that distorted body image is a consideration.
◉ The mother of a child who is taking methylphenidate
hydrochloride (Ritalin) tells the school nurse that she is
