MENTAL AND BEHAVIORAL HEALTH
NURSING EXAM 1 - COMPREHENSIVE
ASSESSMENT
1. A nurse is caring for a client who was involuntarily committed to a behavioral health unit.
The client asks if they still have the right to refuse a prescribed antipsychotic medication.
Which response by the nurse is correct?
A. No, since you are involuntarily committed, you have lost your right to refuse treatment.
B. You can only refuse medication if your family agrees with the decision.
C. Yes, even with involuntary commitment, you retain the right to refuse medication unless
it is an emergency.
D. You can refuse, but we will have to discharge you against medical advice immediately.
Answer: C
Conceptual Explanation: Involuntary commitment does not automatically strip a client of
the right to refuse treatment; legal proceedings are generally required to medicate against
a client’s will unless there is an immediate safety threat.
,2. Which ethical principle is a nurse demonstrating when they spend extra time with a client
who is feeling especially anxious and alone?
A. Autonomy
B. Beneficence
C. Justice
D. Veracity
Answer: B
Conceptual Explanation: Beneficence refers to the quality of doing good and can be
described as charity or taking positive actions to help others.
3. A client in a psychiatric unit tells the nurse, ‘The FBI is listening to my conversations
through the vents.’ Which of the following is the most therapeutic response by the nurse?
A. ‘I don’t see any microphones in the vents, so you must be mistaken.’
B. ‘Why would the FBI want to listen to you?’
C. ‘Let’s go into the hallway where there are no vents so they can’t hear us.’
D. ‘That sounds very frightening. I don’t see anyone from the FBI, but I understand you feel
unsafe.’
Answer: D
Conceptual Explanation: This response acknowledges the client’s feelings (empathy) and
presents reality without arguing with the delusion or validating it.
, 4. A nurse is assessing a client for potential lithium toxicity. Which of the following findings
should the nurse prioritize?
A. Fine hand tremors and mild thirst
B. Blurred vision, ataxia, and persistent gastrointestinal upset
C. Polyuria and acne
D. Weight gain and mild nausea
Answer: B
Conceptual Explanation: Blurred vision, ataxia (uncoordinated movement), and severe GI
upset are advanced signs of lithium toxicity (levels typically > 1.5 mEq/L) and require
immediate intervention.
5. During a nurse-client interaction, the client begins to act toward the nurse in a way that
mimics how they interact with their overbearing mother. This is an example of:
A. Transference
B. Countertransference
C. Resistance
D. Splitting
Answer: A
Conceptual Explanation: Transference occurs when the client displaces feelings and
attitudes held for significant others onto the healthcare provider.
NURSING EXAM 1 - COMPREHENSIVE
ASSESSMENT
1. A nurse is caring for a client who was involuntarily committed to a behavioral health unit.
The client asks if they still have the right to refuse a prescribed antipsychotic medication.
Which response by the nurse is correct?
A. No, since you are involuntarily committed, you have lost your right to refuse treatment.
B. You can only refuse medication if your family agrees with the decision.
C. Yes, even with involuntary commitment, you retain the right to refuse medication unless
it is an emergency.
D. You can refuse, but we will have to discharge you against medical advice immediately.
Answer: C
Conceptual Explanation: Involuntary commitment does not automatically strip a client of
the right to refuse treatment; legal proceedings are generally required to medicate against
a client’s will unless there is an immediate safety threat.
,2. Which ethical principle is a nurse demonstrating when they spend extra time with a client
who is feeling especially anxious and alone?
A. Autonomy
B. Beneficence
C. Justice
D. Veracity
Answer: B
Conceptual Explanation: Beneficence refers to the quality of doing good and can be
described as charity or taking positive actions to help others.
3. A client in a psychiatric unit tells the nurse, ‘The FBI is listening to my conversations
through the vents.’ Which of the following is the most therapeutic response by the nurse?
A. ‘I don’t see any microphones in the vents, so you must be mistaken.’
B. ‘Why would the FBI want to listen to you?’
C. ‘Let’s go into the hallway where there are no vents so they can’t hear us.’
D. ‘That sounds very frightening. I don’t see anyone from the FBI, but I understand you feel
unsafe.’
Answer: D
Conceptual Explanation: This response acknowledges the client’s feelings (empathy) and
presents reality without arguing with the delusion or validating it.
, 4. A nurse is assessing a client for potential lithium toxicity. Which of the following findings
should the nurse prioritize?
A. Fine hand tremors and mild thirst
B. Blurred vision, ataxia, and persistent gastrointestinal upset
C. Polyuria and acne
D. Weight gain and mild nausea
Answer: B
Conceptual Explanation: Blurred vision, ataxia (uncoordinated movement), and severe GI
upset are advanced signs of lithium toxicity (levels typically > 1.5 mEq/L) and require
immediate intervention.
5. During a nurse-client interaction, the client begins to act toward the nurse in a way that
mimics how they interact with their overbearing mother. This is an example of:
A. Transference
B. Countertransference
C. Resistance
D. Splitting
Answer: A
Conceptual Explanation: Transference occurs when the client displaces feelings and
attitudes held for significant others onto the healthcare provider.
