,NUR 253 Exam 4 | Concepts of Mental Health
Nursing (2026/2027) PDF | Nursing | Galen
1. A nurse is caring for a client who is pacing and clenching fists. Which action
should the nurse take first?
A) Use de-escalation techniques such as calm speech and providing personal
space.
B) Administer a PRN antipsychotic immediately.
C) Place the client in seclusion.
D) Call security before speaking to the client.
Correct Answer: A) Use de-escalation techniques such as calm speech and
providing personal space.
Rationale: De-escalation is the first-line intervention for escalating anger to
prevent progression to violence. Seclusion and restraints are used only when
less restrictive measures fail and the client is a danger to self or others.
Medication may be used later if de-escalation is ineffective.
2. A client is placed in seclusion after becoming violent. Which documentation is
essential?
A) The client was placed in seclusion for 2 hours.
B) All other interventions were attempted first, and seclusion was the only
option to ensure safety.
C) The client was calm and cooperative in seclusion.
D) The client's room number and diagnosis.
,Correct Answer: B) All other interventions were attempted first, and seclusion
was the only option to ensure safety.
Rationale: Documentation for seclusion and restraint must demonstrate that
less restrictive measures were tried first and the intervention was necessary for
safety. Merely stating the duration or client's calmness is insufficient. Thorough
documentation protects the client and staff legally and ethically.
3. A nurse is assessing a child with conduct disorder. Which behavior is most
characteristic?
A) Inattention and impulsivity.
B) Repetitive pattern of violating the rights of others.
C) Deficits in social communication.
D) Intense fear of weight gain.
Correct Answer: C) Repetitive pattern of violating the rights of others.
Rationale: Conduct disorder is defined by a persistent pattern of behavior that
violates the rights of others or societal norms, including aggression, destruction
of property, deceitfulness, and serious rule violations. Inattention and
impulsivity are ADHD, social deficits are autism, and fear of weight gain is
anorexia.
4. A client is in the acute battering stage of the cycle of violence. What is the
priority nursing action?
A) Provide emotional support and validation.
B) Ensure the client's safety and provide a safe environment.
, C) Encourage the client to forgive the abuser.
D) Discuss the honeymoon stage with the client.
Correct Answer: D) Ensure the client's safety and provide a safe environment.
Rationale: During the acute battering stage, the priority is physical safety. The
nurse should assess injuries, provide a safe environment, and offer resources
such as shelters. Emotional support is important but secondary to immediate
safety. Discussing forgiveness or the honeymoon stage is inappropriate.
5. A client with borderline personality disorder is engaging in self-destructive
behaviors. Which nursing intervention is most appropriate?
A) Establish a safety contract and provide close monitoring.
B) Place the client in seclusion.
C) Administer a PRN antipsychotic medication.
D) Ignore the behavior to avoid reinforcing it.
Correct Answer: A) Establish a safety contract and provide close monitoring.
Rationale: Safety is the priority for clients with borderline personality disorder
who self-harm. A safety contract and close monitoring promote safety and build
trust. Seclusion and PRN medications are not first-line for self-harm; ignoring
the behavior is unsafe and nontherapeutic.
6. A nurse is teaching a family about safety for a client with Alzheimer's disease.
Which intervention should be included?
A) Provide a structured routine and a safe environment.
Nursing (2026/2027) PDF | Nursing | Galen
1. A nurse is caring for a client who is pacing and clenching fists. Which action
should the nurse take first?
A) Use de-escalation techniques such as calm speech and providing personal
space.
B) Administer a PRN antipsychotic immediately.
C) Place the client in seclusion.
D) Call security before speaking to the client.
Correct Answer: A) Use de-escalation techniques such as calm speech and
providing personal space.
Rationale: De-escalation is the first-line intervention for escalating anger to
prevent progression to violence. Seclusion and restraints are used only when
less restrictive measures fail and the client is a danger to self or others.
Medication may be used later if de-escalation is ineffective.
2. A client is placed in seclusion after becoming violent. Which documentation is
essential?
A) The client was placed in seclusion for 2 hours.
B) All other interventions were attempted first, and seclusion was the only
option to ensure safety.
C) The client was calm and cooperative in seclusion.
D) The client's room number and diagnosis.
,Correct Answer: B) All other interventions were attempted first, and seclusion
was the only option to ensure safety.
Rationale: Documentation for seclusion and restraint must demonstrate that
less restrictive measures were tried first and the intervention was necessary for
safety. Merely stating the duration or client's calmness is insufficient. Thorough
documentation protects the client and staff legally and ethically.
3. A nurse is assessing a child with conduct disorder. Which behavior is most
characteristic?
A) Inattention and impulsivity.
B) Repetitive pattern of violating the rights of others.
C) Deficits in social communication.
D) Intense fear of weight gain.
Correct Answer: C) Repetitive pattern of violating the rights of others.
Rationale: Conduct disorder is defined by a persistent pattern of behavior that
violates the rights of others or societal norms, including aggression, destruction
of property, deceitfulness, and serious rule violations. Inattention and
impulsivity are ADHD, social deficits are autism, and fear of weight gain is
anorexia.
4. A client is in the acute battering stage of the cycle of violence. What is the
priority nursing action?
A) Provide emotional support and validation.
B) Ensure the client's safety and provide a safe environment.
, C) Encourage the client to forgive the abuser.
D) Discuss the honeymoon stage with the client.
Correct Answer: D) Ensure the client's safety and provide a safe environment.
Rationale: During the acute battering stage, the priority is physical safety. The
nurse should assess injuries, provide a safe environment, and offer resources
such as shelters. Emotional support is important but secondary to immediate
safety. Discussing forgiveness or the honeymoon stage is inappropriate.
5. A client with borderline personality disorder is engaging in self-destructive
behaviors. Which nursing intervention is most appropriate?
A) Establish a safety contract and provide close monitoring.
B) Place the client in seclusion.
C) Administer a PRN antipsychotic medication.
D) Ignore the behavior to avoid reinforcing it.
Correct Answer: A) Establish a safety contract and provide close monitoring.
Rationale: Safety is the priority for clients with borderline personality disorder
who self-harm. A safety contract and close monitoring promote safety and build
trust. Seclusion and PRN medications are not first-line for self-harm; ignoring
the behavior is unsafe and nontherapeutic.
6. A nurse is teaching a family about safety for a client with Alzheimer's disease.
Which intervention should be included?
A) Provide a structured routine and a safe environment.
