HESI COMPASS MODULE EXAM 4 EXAM
SCRIPT 2026 EMERGENCY NURSING
INTERVENTIONS COMPLETE SOLUTION
VIEW
◉ A client with schizophrenia and his parents are meeting with the
nurse. One of the young man's parents says to the nurse, "We were
stunned when we learned that our son had schizophrenia. He was no
different than from his older brother when they were growing up.
Now he's had another relapse, and we can't understand why he
stopped his medication." Which response by the nurse is
appropriate?
Answer: Cclient, "How can we help you to take your medicine or to
tell us when you're having problems so that your medication can be
adjusted?"
◉ An acutely ill schizophrenic client says to the nurse, "He keeps
saying that he likes you, and I keep telling him you're married, but
he won't listen, and I think he's going to get fresh with you." Once the
nurse has determined that the client is hallucinating, which
response to the client would be most appropriate statement?
Answer: A "Try not to listen to the voices right now so that I can talk
with you."
,Rationale: The appropriate statement by the nurse is the one that
does not acknowledge the client's hallucinations. By responding, "I
think that you can help him stop his behavior if you concentrate" or
"Tell him I said to mind his p's and q's or I'll call the police on him,"
the nurse acknowledges the hallucinations. The nurse attempts to
interpret the client's thinking with a statement such as "I think that
you're trying to share your own feelings toward me, but you're shy."
◉ A client says to the nurse, "It's over for me — the whole thing is
over." Which response by the nurse would be therapeutic?
Answer: "Let's talk more about your feeling that the whole thing is
over for you. This is important, and I may need to share your feelings
with other staff members."
Rationale: The therapeutic response seeks clarification, employs
paraphrasing, and informs the client that the nurse needs to share
any information that requires crisis intervention with other staff
members. Asking, "What do you mean, 'The whole thing is over'?"
employs paraphrasing, but the message is blunt and closed-ended.
In stating, "Over? Well, that sounds pretty drastic to me. Let's discuss
this in the strictest confidence," the nurse uses hysterical
exaggeration (at an inappropriate time) and gives incorrect
information regarding confidentiality. In stating, "Can you tell me
more about why it's over for you? I'll keep your thoughts strictly
confidential," the nurse uses the therapeutic technique of seeking
,clarification but does not clarify with the client that the information
might need to be shared.
◉ A nurse performing a lethality assessment asks the client whether
he is thinking of suicide. Which statement by the client would be of
most concern to the nurse?
Answer: "No, I wasn't, but I am now, thanks to you."
Rationale: The client's response that he is now thinking about
suicide is of the greatest concern to the nurse. In making the
statement "I hadn't thought of that, but I can see that you are" the
client projects his own thoughts of suicide onto the nurse. In stating,
"Of course not, but there are days when I think that I should be," the
client is being sarcastic but is not specifically talking about suicide.
In stating, "What is suicide going to do for me except get me
excommunicated from the church?" the client indicates that suicide
is not an option because of his religious beliefs.
◉ A client who has expressed suicidal ideation in the past says to the
nurse, while shuffling several documents in an effort to organize
them, "Well, I'm feeling so much better now since I got organized.
My lawyer wrote my will and durable power of attorney." Which
response by the nurse is appropriate?
Answer: "You talk about getting organized. Are you thinking of
killing yourself?"
, Rationale: The client is exhibiting behaviors that indicate plans for
suicide. Talking of suddenly "feeling so much better" and putting
affairs in order are key verbal and behavioral clues that the client is
planning to commit suicide. In exclaiming, "Good grief! You don't
look organized to me," the nurse nontherapeutically uses hysterical
exaggeration, which minimizes the client's feelings. In asking, "Okay,
what are you up to today? Your behavior is not appropriate," the
nurse uses teasing to determine the client's behaviors, which
minimizes them. Additionally, the nurse is employing a
nontherapeutic technique of judging. In stating, "If you keep
behaving like this, you know that I'll have to tell the doctor and we'll
have to seclude you," the nurse uses a threat.
◉ An adolescent client says, "I'm just a burden to my folks. They
wish I'd never been born. My dad told me he had to marry Mom
because she got pregnant." Which response by the nurse would be
therapeutic?
Answer: "You're feeling that your folks didn't want you, but they
chose to marry and have you."
Rationale: In the correct option, the nurse uses reflection to explore
the client's lethality risk and then uses reframing to determine
whether the client is able to view what happened in a different way.
In suggesting, "You feel that you were a burden and not wanted?
Let's talk with your parents to see whether you're right," the nurse
uses paraphrasing but is then nontherapeutic in trying to persuade
the client to talk to the parents. In suggesting, "Let's speak with your
parents about what you've just told me. Let's ask whether you were
SCRIPT 2026 EMERGENCY NURSING
INTERVENTIONS COMPLETE SOLUTION
VIEW
◉ A client with schizophrenia and his parents are meeting with the
nurse. One of the young man's parents says to the nurse, "We were
stunned when we learned that our son had schizophrenia. He was no
different than from his older brother when they were growing up.
Now he's had another relapse, and we can't understand why he
stopped his medication." Which response by the nurse is
appropriate?
Answer: Cclient, "How can we help you to take your medicine or to
tell us when you're having problems so that your medication can be
adjusted?"
◉ An acutely ill schizophrenic client says to the nurse, "He keeps
saying that he likes you, and I keep telling him you're married, but
he won't listen, and I think he's going to get fresh with you." Once the
nurse has determined that the client is hallucinating, which
response to the client would be most appropriate statement?
Answer: A "Try not to listen to the voices right now so that I can talk
with you."
,Rationale: The appropriate statement by the nurse is the one that
does not acknowledge the client's hallucinations. By responding, "I
think that you can help him stop his behavior if you concentrate" or
"Tell him I said to mind his p's and q's or I'll call the police on him,"
the nurse acknowledges the hallucinations. The nurse attempts to
interpret the client's thinking with a statement such as "I think that
you're trying to share your own feelings toward me, but you're shy."
◉ A client says to the nurse, "It's over for me — the whole thing is
over." Which response by the nurse would be therapeutic?
Answer: "Let's talk more about your feeling that the whole thing is
over for you. This is important, and I may need to share your feelings
with other staff members."
Rationale: The therapeutic response seeks clarification, employs
paraphrasing, and informs the client that the nurse needs to share
any information that requires crisis intervention with other staff
members. Asking, "What do you mean, 'The whole thing is over'?"
employs paraphrasing, but the message is blunt and closed-ended.
In stating, "Over? Well, that sounds pretty drastic to me. Let's discuss
this in the strictest confidence," the nurse uses hysterical
exaggeration (at an inappropriate time) and gives incorrect
information regarding confidentiality. In stating, "Can you tell me
more about why it's over for you? I'll keep your thoughts strictly
confidential," the nurse uses the therapeutic technique of seeking
,clarification but does not clarify with the client that the information
might need to be shared.
◉ A nurse performing a lethality assessment asks the client whether
he is thinking of suicide. Which statement by the client would be of
most concern to the nurse?
Answer: "No, I wasn't, but I am now, thanks to you."
Rationale: The client's response that he is now thinking about
suicide is of the greatest concern to the nurse. In making the
statement "I hadn't thought of that, but I can see that you are" the
client projects his own thoughts of suicide onto the nurse. In stating,
"Of course not, but there are days when I think that I should be," the
client is being sarcastic but is not specifically talking about suicide.
In stating, "What is suicide going to do for me except get me
excommunicated from the church?" the client indicates that suicide
is not an option because of his religious beliefs.
◉ A client who has expressed suicidal ideation in the past says to the
nurse, while shuffling several documents in an effort to organize
them, "Well, I'm feeling so much better now since I got organized.
My lawyer wrote my will and durable power of attorney." Which
response by the nurse is appropriate?
Answer: "You talk about getting organized. Are you thinking of
killing yourself?"
, Rationale: The client is exhibiting behaviors that indicate plans for
suicide. Talking of suddenly "feeling so much better" and putting
affairs in order are key verbal and behavioral clues that the client is
planning to commit suicide. In exclaiming, "Good grief! You don't
look organized to me," the nurse nontherapeutically uses hysterical
exaggeration, which minimizes the client's feelings. In asking, "Okay,
what are you up to today? Your behavior is not appropriate," the
nurse uses teasing to determine the client's behaviors, which
minimizes them. Additionally, the nurse is employing a
nontherapeutic technique of judging. In stating, "If you keep
behaving like this, you know that I'll have to tell the doctor and we'll
have to seclude you," the nurse uses a threat.
◉ An adolescent client says, "I'm just a burden to my folks. They
wish I'd never been born. My dad told me he had to marry Mom
because she got pregnant." Which response by the nurse would be
therapeutic?
Answer: "You're feeling that your folks didn't want you, but they
chose to marry and have you."
Rationale: In the correct option, the nurse uses reflection to explore
the client's lethality risk and then uses reframing to determine
whether the client is able to view what happened in a different way.
In suggesting, "You feel that you were a burden and not wanted?
Let's talk with your parents to see whether you're right," the nurse
uses paraphrasing but is then nontherapeutic in trying to persuade
the client to talk to the parents. In suggesting, "Let's speak with your
parents about what you've just told me. Let's ask whether you were
