WILKES NSG 526 FINAL EXAM STUDY
GUIDE 2026 | CUMULATIVE REVIEW
400+ PRACTICE QUESTIONS
+RATIONALES | ADVANCED
PHARMACOLOGY
A patient with depression states, “My life has no meaning, and my family would be better
off without me.” Which action should the psychiatric nurse practitioner take first?
A. Encourage the patient to identify positive qualities
B. Ask directly about suicidal thoughts, intent, plan, and access to means
C. Recommend increased exercise
D. Explore childhood relationships
Correct answer: B. Ask directly about suicidal thoughts, intent, plan, and access to
means
Expert rationale: Statements involving hopelessness and perceived burdensomeness
require immediate suicide-risk assessment. The clinician should ask clearly whether the
patient is thinking about dying or killing themselves, whether they have a plan, whether
they intend to act, what means are available, when they might act, and whether they have
made preparations. Additional assessment includes prior attempts, self-harm, substance
use, psychosis, agitation, sleep, protective factors, and the ability to remain safe. Positive-
thinking advice and exercise may be useful later but do not address possible imminent
danger. Exploring childhood relationships should not precede immediate safety evaluation.
A patient reports having a firearm, a written suicide note, and a plan to overdose but denies
current intent. Which finding is most concerning?
A. The patient denies current intent
B. The patient has made preparatory acts and has access to lethal means
C. The patient is willing to attend therapy
D. The patient identifies one reason for living
,Correct answer: B. The patient has made preparatory acts and has access to lethal
means
Expert rationale: A suicide note, access to a firearm, and a specific overdose plan are
significant risk indicators even when the patient denies current intent. Denial may reflect
ambivalence, shame, fear of hospitalization, intoxication, or a recent change in intent. The
clinician should complete an urgent comprehensive assessment, ensure the patient is not
left alone, address lethal-means safety, involve appropriate supports or emergency
services, and follow legal and institutional procedures. Protective factors are important but
do not negate preparatory behavior.
A patient experiencing psychosis reports a voice commanding them to kill a neighbor.
Which question is most important?
A. “How long have you heard voices?”
B. “What is the neighbor’s occupation?”
C. “Do you intend to follow the command, and do you have access to a weapon?”
D. “Have you tried ignoring the voice?”
Correct answer: C. “Do you intend to follow the command, and do you have access to
a weapon?”
Expert rationale: Command hallucinations involving a specific person require immediate
assessment of violence risk. The clinician should determine the patient’s level of
conviction, perceived control, intention to obey, target access, weapon access, past
compliance with commands, substance use, psychosis severity, and protective factors.
The patient should not be left alone if danger is imminent. The clinician should use calm,
direct communication and activate emergency safety procedures when indicated.
A patient reports new confusion, fluctuating attention, visual hallucinations, fever, and
drowsiness. Which condition should be suspected first?
A. Delirium
B. Schizoid personality disorder
C. Generalized anxiety disorder
D. Histrionic personality disorder
Correct answer: A. Delirium
Expert rationale: Acute onset, fluctuating attention, altered consciousness, and visual
hallucinations are highly concerning for delirium. Delirium is usually caused by an
underlying medical, medication-related, neurological, or substance-related condition. The
clinician should assess vital signs, oxygenation, infection, medications, intoxication or
,withdrawal, hydration, pain, metabolic abnormalities, and neurological symptoms.
Delirium is a medical emergency and should not be mistaken for a primary psychotic
disorder or personality disorder.
A patient has decreased need for sleep, pressured speech, grandiosity, impulsive
spending, and increased goal-directed activity. Which diagnosis should be considered?
A. Manic episode
B. Persistent depressive disorder
C. Obsessive-compulsive disorder
D. Social anxiety disorder
Correct answer: A. Manic episode
Expert rationale: The combination of elevated or irritable mood, decreased need for sleep,
pressured speech, grandiosity, increased activity, and risky behavior is characteristic of
mania. The clinician should evaluate duration, impairment, psychosis, hospitalization,
substance use, medication effects, and prior episodes. The patient may view the behavior
as productive or desirable, so collateral information can be helpful. Medical and
substance-induced causes must also be considered.
A patient with borderline personality disorder says, “If you do not call me back immediately,
I will kill myself.” What is the most appropriate initial response?
A. Promise to call back immediately every time
B. Tell the patient the statement is manipulative
C. Complete an immediate suicide-risk assessment
D. End the therapeutic relationship
Correct answer: C. Complete an immediate suicide-risk assessment
Expert rationale: Suicidal statements require direct assessment regardless of whether
they occur in an interpersonal context or may serve a relational function. The clinician
should evaluate intent, plan, means, timing, prior attempts, self-harm, substance use,
psychosis, protective factors, and ability to maintain safety. The clinician should validate
distress without rewarding threats through unlimited availability or special treatment. DBT
may later address abandonment fears and interpersonal effectiveness, but immediate
safety takes priority.
Which intervention is most consistent with dialectical behavior therapy?
A. Exploring unconscious conflicts exclusively
B. Combining acceptance of the patient’s experience with efforts to change dangerous or
, ineffective behavior
C. Providing reassurance whenever distress occurs
D. Avoiding discussion of self-harm
Correct answer: B. Combining acceptance of the patient’s experience with efforts to
change dangerous or ineffective behavior
Expert rationale: DBT is based on a dialectical balance between acceptance and change.
The clinician validates the patient’s emotions and history while helping them reduce self-
harm, suicidal behavior, impulsivity, and interpersonal dysfunction. Core skills include
mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
Validation does not mean approving unsafe behavior, and change strategies should not
communicate rejection.
A patient self-injures after an argument with a partner. Which DBT technique should be
used to understand the behavior?
A. Behavior chain analysis
B. Free association
C. Dream interpretation
D. Flooding
Correct answer: A. Behavior chain analysis
Expert rationale: Chain analysis examines vulnerability factors, prompting events,
thoughts, emotions, body sensations, urges, behaviors, consequences, and points where
alternative skills might have been used. The clinician should first assess injury, suicidal
intent, lethality, access to means, and immediate safety. The goal is to understand the
function of self-harm and identify replacement skills rather than blame or shame the
patient.
A patient with obsessive-compulsive symptoms repeatedly asks, “Are you sure I did not
harm someone?” Which response is most appropriate?
A. Provide reassurance every time
B. Identify reassurance-seeking as a possible compulsion and develop a response-
prevention plan
C. Tell the patient they may have harmed someone
D. Ignore the patient completely
Correct answer: B. Identify reassurance-seeking as a possible compulsion and
develop a response-prevention plan
GUIDE 2026 | CUMULATIVE REVIEW
400+ PRACTICE QUESTIONS
+RATIONALES | ADVANCED
PHARMACOLOGY
A patient with depression states, “My life has no meaning, and my family would be better
off without me.” Which action should the psychiatric nurse practitioner take first?
A. Encourage the patient to identify positive qualities
B. Ask directly about suicidal thoughts, intent, plan, and access to means
C. Recommend increased exercise
D. Explore childhood relationships
Correct answer: B. Ask directly about suicidal thoughts, intent, plan, and access to
means
Expert rationale: Statements involving hopelessness and perceived burdensomeness
require immediate suicide-risk assessment. The clinician should ask clearly whether the
patient is thinking about dying or killing themselves, whether they have a plan, whether
they intend to act, what means are available, when they might act, and whether they have
made preparations. Additional assessment includes prior attempts, self-harm, substance
use, psychosis, agitation, sleep, protective factors, and the ability to remain safe. Positive-
thinking advice and exercise may be useful later but do not address possible imminent
danger. Exploring childhood relationships should not precede immediate safety evaluation.
A patient reports having a firearm, a written suicide note, and a plan to overdose but denies
current intent. Which finding is most concerning?
A. The patient denies current intent
B. The patient has made preparatory acts and has access to lethal means
C. The patient is willing to attend therapy
D. The patient identifies one reason for living
,Correct answer: B. The patient has made preparatory acts and has access to lethal
means
Expert rationale: A suicide note, access to a firearm, and a specific overdose plan are
significant risk indicators even when the patient denies current intent. Denial may reflect
ambivalence, shame, fear of hospitalization, intoxication, or a recent change in intent. The
clinician should complete an urgent comprehensive assessment, ensure the patient is not
left alone, address lethal-means safety, involve appropriate supports or emergency
services, and follow legal and institutional procedures. Protective factors are important but
do not negate preparatory behavior.
A patient experiencing psychosis reports a voice commanding them to kill a neighbor.
Which question is most important?
A. “How long have you heard voices?”
B. “What is the neighbor’s occupation?”
C. “Do you intend to follow the command, and do you have access to a weapon?”
D. “Have you tried ignoring the voice?”
Correct answer: C. “Do you intend to follow the command, and do you have access to
a weapon?”
Expert rationale: Command hallucinations involving a specific person require immediate
assessment of violence risk. The clinician should determine the patient’s level of
conviction, perceived control, intention to obey, target access, weapon access, past
compliance with commands, substance use, psychosis severity, and protective factors.
The patient should not be left alone if danger is imminent. The clinician should use calm,
direct communication and activate emergency safety procedures when indicated.
A patient reports new confusion, fluctuating attention, visual hallucinations, fever, and
drowsiness. Which condition should be suspected first?
A. Delirium
B. Schizoid personality disorder
C. Generalized anxiety disorder
D. Histrionic personality disorder
Correct answer: A. Delirium
Expert rationale: Acute onset, fluctuating attention, altered consciousness, and visual
hallucinations are highly concerning for delirium. Delirium is usually caused by an
underlying medical, medication-related, neurological, or substance-related condition. The
clinician should assess vital signs, oxygenation, infection, medications, intoxication or
,withdrawal, hydration, pain, metabolic abnormalities, and neurological symptoms.
Delirium is a medical emergency and should not be mistaken for a primary psychotic
disorder or personality disorder.
A patient has decreased need for sleep, pressured speech, grandiosity, impulsive
spending, and increased goal-directed activity. Which diagnosis should be considered?
A. Manic episode
B. Persistent depressive disorder
C. Obsessive-compulsive disorder
D. Social anxiety disorder
Correct answer: A. Manic episode
Expert rationale: The combination of elevated or irritable mood, decreased need for sleep,
pressured speech, grandiosity, increased activity, and risky behavior is characteristic of
mania. The clinician should evaluate duration, impairment, psychosis, hospitalization,
substance use, medication effects, and prior episodes. The patient may view the behavior
as productive or desirable, so collateral information can be helpful. Medical and
substance-induced causes must also be considered.
A patient with borderline personality disorder says, “If you do not call me back immediately,
I will kill myself.” What is the most appropriate initial response?
A. Promise to call back immediately every time
B. Tell the patient the statement is manipulative
C. Complete an immediate suicide-risk assessment
D. End the therapeutic relationship
Correct answer: C. Complete an immediate suicide-risk assessment
Expert rationale: Suicidal statements require direct assessment regardless of whether
they occur in an interpersonal context or may serve a relational function. The clinician
should evaluate intent, plan, means, timing, prior attempts, self-harm, substance use,
psychosis, protective factors, and ability to maintain safety. The clinician should validate
distress without rewarding threats through unlimited availability or special treatment. DBT
may later address abandonment fears and interpersonal effectiveness, but immediate
safety takes priority.
Which intervention is most consistent with dialectical behavior therapy?
A. Exploring unconscious conflicts exclusively
B. Combining acceptance of the patient’s experience with efforts to change dangerous or
, ineffective behavior
C. Providing reassurance whenever distress occurs
D. Avoiding discussion of self-harm
Correct answer: B. Combining acceptance of the patient’s experience with efforts to
change dangerous or ineffective behavior
Expert rationale: DBT is based on a dialectical balance between acceptance and change.
The clinician validates the patient’s emotions and history while helping them reduce self-
harm, suicidal behavior, impulsivity, and interpersonal dysfunction. Core skills include
mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
Validation does not mean approving unsafe behavior, and change strategies should not
communicate rejection.
A patient self-injures after an argument with a partner. Which DBT technique should be
used to understand the behavior?
A. Behavior chain analysis
B. Free association
C. Dream interpretation
D. Flooding
Correct answer: A. Behavior chain analysis
Expert rationale: Chain analysis examines vulnerability factors, prompting events,
thoughts, emotions, body sensations, urges, behaviors, consequences, and points where
alternative skills might have been used. The clinician should first assess injury, suicidal
intent, lethality, access to means, and immediate safety. The goal is to understand the
function of self-harm and identify replacement skills rather than blame or shame the
patient.
A patient with obsessive-compulsive symptoms repeatedly asks, “Are you sure I did not
harm someone?” Which response is most appropriate?
A. Provide reassurance every time
B. Identify reassurance-seeking as a possible compulsion and develop a response-
prevention plan
C. Tell the patient they may have harmed someone
D. Ignore the patient completely
Correct answer: B. Identify reassurance-seeking as a possible compulsion and
develop a response-prevention plan
