Unit 4: Foundations of Psychiatric
Nursing Passed A+ Rated Guideline
Questions And Answers 2025
During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over
spilled milk." The purpose of this is to evaluate the client's ability to think: - Answer - abstractly.
Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual
functioning than concrete thinking, in which the client explains the proverb by its literal meaning.
Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential
thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain
disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They
interpret such statements as "Don't cry over spilled milk" in a literal sense, such as "Even if you spill your
milk, you shouldn't cry about it."
A client is complaining to other clients about not being allowed by staff to keep food in the client's room.
What should the nurse do? - Answer - Set limits on the behavior.
The nurse needs to set limits on the client's manipulative behavior to help the client control
dysfunctional behavior. The manipulative client bends rules to have needs met without regard for rules
or the needs or rights of others. A consistent approach by the staff is necessary to decrease
manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the client's
manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in aggressive
behavior. Allowing the client to keep a snack in the client's room reinforces the dysfunctional behavior.
A nurse is counseling a married woman who has two children under 4 years of age and is a victim of
spousal abuse. Before the client leaves the clinic, what is the most important thing the nurse should do?
- Answer - Help the client develop a safety plan.
It is most important for the nurse to help the client develop a safety plan because the abuse will occur
again, and the client will need a plan to seek a safe environment for herself and her children.Teaching
about the cycle of violence is not as important as the client's safety and the safety of her
children.Discussing the abuser's behaviors is not as important as the client's safety and the safety of her
children.Giving the client the name of a domestic violence shelter can be part of the safety plan, but the
,nurse needs to assure other safety measures are in place until the woman is ready to leave the abusive
partner.
Which intervention(s) should the nurse include in the plan of care for a school-age child with an autism
spectrum disorder who has been admitted to the hospital? Select all that apply. - Answer - Allow a family
member in the room 24 hours per day.
Limit the number of health care providers and nurses interacting with the child.
Dim lights and keep noise levels low.
Show medical equipment to the child before procedures.
Have family member bring possessions from home.
Children with an autism spectrum prefer routine and familiarity. Having a family member in the room 24
hours a day may decrease the child's anxiety. Limiting the number of different health care providers and
nurses that interact with the child may also help reduce anxiety. Dimming lights and keeping noise levels
low will reduce sensory stimulation. Introducing a child with an autism spectrum disorder to equipment
prior to a procedure may help reduce anxiety. Bringing in possessions from home will help with routine
and familiarity. People with an autism spectrum disorder often have a limited ability to communicate.
Health care providers need to approach a child with an autism spectrum disorder carefully with minimal
touch and clear and concise instructions; their interactions should be brief.
A nurse is assessing military personnel who have experienced combat and are diagnosed with
posttraumatic stress disorder. Which client statement requires immediate intervention? - Answer - I
cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not worth it."
Client safety is the priority. Increased use of opioids and stating "it is not worth it" can be considered
suicidal. A client who increased lorazepam intake requires follow up, but this client is not the priority.
Increasing benzodiazepine will cause fatigue, so afternoon naps are expected. Increasing the frequency
of visits to a therapist are encouraged; there are no immediate concerns with seeing a therapist more
often. Avoiding alcohol with posttraumatic stress disorder is encouraged; however, there's nothing
immediately concerning with an adult having one glass of wine with supper.
The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a
psychiatric aide. This assignment is considered: - Answer - reasonable nursing practice because one-on-
one requires the total attention of a staff member
,A psychiatric aide may sit with a client to ensure safety. The nurse is still responsible for assessing the
client and ensuring that one-on-one supervision occurs. Aides are capable of providing one-to-one
observation. It isn't illegal to delegate observation to an aide.
During an assessment interview, a depressed 15-year-old client reports "I can't sleep at night." The nurse
begins to explore factors that might contribute to this situation by asking if the client is sexually active.
The client changes the subject. What should the nurse suspect based on the client's response to the
assessment question? - Answer - sexual abuse
Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because they
have been threatened by their abuser. Although there may be other explanations for the adolescent's
inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other disturbances,
adolescents are typically willing to discuss these factors as contributors to their inability to sleep. An
adolescent with narcolepsy would experience brief periods of deep sleep followed by periods of feeling
refreshed and wouldn't complain of being unable to sleep at night.
A client lives in a group home and visits the community mental health center regularly. During one visit
with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the
nurse is most important to ask? - Answer - Are you going to hurt yourself?"
The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to
cope with the voices and to assess the client's impulse control. The nurse's assessment will then
determine the course of action to take regarding the client's safety. Asking when the client hears the
voices and how long the client has heard them is important but not as important as determining
whether the client will act on what the voices are saying. Asking, "Why are the voices starting again?"
would be inappropriate because the client may not know why and may not be able to answer the nurse.
An older adult experiences short-term memory problems and occasional disorientation a few weeks
after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in
the kitchen. The home care nurse calls the woman's health care provider to discuss the client's situation
and background, assess, and give recommendations. The nurse concludes that the client most likely has
which problem? - Answer - delirium and a urinary tract infection (UTI)
Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium often involves
memory problems, disorientation, and hallucinations. It develops rather quickly. There are not enough
data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and
adjusting to being alone are unlikely to cause hallucinations.
, A client has been involuntarily committed to a hospital because he has been assessed as being
dangerous to self or others. The client has lost which right? - Answer - the right to leave the hospital
against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable enough
that the client no longer poses a danger to self or others. While hospitalized, the client retains all civil
rights such as receiving mail, making phone calls, refusing treatment, and also receiving the least
restrictive treatment. Should the involuntarily admitted client refuse treatment once admitted, he will be
evaluated for the need to receive treatment against wishes in order to decrease the risk for self-harm or
harm to others.
A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress
with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which
goal should the nurse identify as the initial priority when planning this client's care? - Answer - helping
the client feel safe and accepted
The initial priority for this client is to help her overcome suspiciousness of others, including staff, and
thereby feel safe and accepted. Introducing the client to others, giving the client information about the
program, and providing clean clothes are important, but these are of lower priority than helping the
client feel safe and accepted.
After talking with the nurse, a client admits to being physically abused by her husband. She says that she
has never called the police because her husband has threatened to kill her if she does. She says, "I don't
want to get him into trouble, because he's the father of my children. I don't know what to do!" Which
nursing intervention would be most therapeutic at this time? - Answer - Express concern for the client's
safety.
The nurse's expression of concern for the client's safety may help the client validate her fears and choose
to take action.
Talking to the client about changing her behavior is a form of victim blaming and reinforces the message
that the client is responsible for the abuse. She is likely getting the same message from the abuser and
others.
Talking to the client about reducing family stress is also a form of victim blaming.
Telling the client to leave her husband is inappropriate advice. The idea of leaving the marriage may be
so overwhelming that it may push the client away from the nurse as a support person.
Nursing Passed A+ Rated Guideline
Questions And Answers 2025
During the mental status examination, a client may be asked to explain such proverbs as "Don't cry over
spilled milk." The purpose of this is to evaluate the client's ability to think: - Answer - abstractly.
Abstract thinking is the ability to conceptualize and interpret meaning. It's a higher level of intellectual
functioning than concrete thinking, in which the client explains the proverb by its literal meaning.
Rational thinking involves the ability to think logically, make judgments, and be goal-directed. Tangential
thinking is scattered, non-goal-directed, and hard to follow. Clients with such conditions as organic brain
disease and schizophrenia typically can't conceptualize and comprehend abstract meaning. They
interpret such statements as "Don't cry over spilled milk" in a literal sense, such as "Even if you spill your
milk, you shouldn't cry about it."
A client is complaining to other clients about not being allowed by staff to keep food in the client's room.
What should the nurse do? - Answer - Set limits on the behavior.
The nurse needs to set limits on the client's manipulative behavior to help the client control
dysfunctional behavior. The manipulative client bends rules to have needs met without regard for rules
or the needs or rights of others. A consistent approach by the staff is necessary to decrease
manipulation. Ignoring the client's behavior reinforces or promotes the continuation of the client's
manipulative behavior. Reprimanding the client may be perceived as a threat, resulting in aggressive
behavior. Allowing the client to keep a snack in the client's room reinforces the dysfunctional behavior.
A nurse is counseling a married woman who has two children under 4 years of age and is a victim of
spousal abuse. Before the client leaves the clinic, what is the most important thing the nurse should do?
- Answer - Help the client develop a safety plan.
It is most important for the nurse to help the client develop a safety plan because the abuse will occur
again, and the client will need a plan to seek a safe environment for herself and her children.Teaching
about the cycle of violence is not as important as the client's safety and the safety of her
children.Discussing the abuser's behaviors is not as important as the client's safety and the safety of her
children.Giving the client the name of a domestic violence shelter can be part of the safety plan, but the
,nurse needs to assure other safety measures are in place until the woman is ready to leave the abusive
partner.
Which intervention(s) should the nurse include in the plan of care for a school-age child with an autism
spectrum disorder who has been admitted to the hospital? Select all that apply. - Answer - Allow a family
member in the room 24 hours per day.
Limit the number of health care providers and nurses interacting with the child.
Dim lights and keep noise levels low.
Show medical equipment to the child before procedures.
Have family member bring possessions from home.
Children with an autism spectrum prefer routine and familiarity. Having a family member in the room 24
hours a day may decrease the child's anxiety. Limiting the number of different health care providers and
nurses that interact with the child may also help reduce anxiety. Dimming lights and keeping noise levels
low will reduce sensory stimulation. Introducing a child with an autism spectrum disorder to equipment
prior to a procedure may help reduce anxiety. Bringing in possessions from home will help with routine
and familiarity. People with an autism spectrum disorder often have a limited ability to communicate.
Health care providers need to approach a child with an autism spectrum disorder carefully with minimal
touch and clear and concise instructions; their interactions should be brief.
A nurse is assessing military personnel who have experienced combat and are diagnosed with
posttraumatic stress disorder. Which client statement requires immediate intervention? - Answer - I
cannot stop the nightmares, even the extra oxycodone pills I take do not work. It is not worth it."
Client safety is the priority. Increased use of opioids and stating "it is not worth it" can be considered
suicidal. A client who increased lorazepam intake requires follow up, but this client is not the priority.
Increasing benzodiazepine will cause fatigue, so afternoon naps are expected. Increasing the frequency
of visits to a therapist are encouraged; there are no immediate concerns with seeing a therapist more
often. Avoiding alcohol with posttraumatic stress disorder is encouraged; however, there's nothing
immediately concerning with an adult having one glass of wine with supper.
The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a
psychiatric aide. This assignment is considered: - Answer - reasonable nursing practice because one-on-
one requires the total attention of a staff member
,A psychiatric aide may sit with a client to ensure safety. The nurse is still responsible for assessing the
client and ensuring that one-on-one supervision occurs. Aides are capable of providing one-to-one
observation. It isn't illegal to delegate observation to an aide.
During an assessment interview, a depressed 15-year-old client reports "I can't sleep at night." The nurse
begins to explore factors that might contribute to this situation by asking if the client is sexually active.
The client changes the subject. What should the nurse suspect based on the client's response to the
assessment question? - Answer - sexual abuse
Victims of sexual abuse commonly refuse to talk about the abuse or change the subject because they
have been threatened by their abuser. Although there may be other explanations for the adolescent's
inability to sleep at night, such as noise, anxiety, spiritual distress, pain, or other disturbances,
adolescents are typically willing to discuss these factors as contributors to their inability to sleep. An
adolescent with narcolepsy would experience brief periods of deep sleep followed by periods of feeling
refreshed and wouldn't complain of being unable to sleep at night.
A client lives in a group home and visits the community mental health center regularly. During one visit
with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the
nurse is most important to ask? - Answer - Are you going to hurt yourself?"
The nurse needs to ask the client whether he is going to hurt himself to determine the client's ability to
cope with the voices and to assess the client's impulse control. The nurse's assessment will then
determine the course of action to take regarding the client's safety. Asking when the client hears the
voices and how long the client has heard them is important but not as important as determining
whether the client will act on what the voices are saying. Asking, "Why are the voices starting again?"
would be inappropriate because the client may not know why and may not be able to answer the nurse.
An older adult experiences short-term memory problems and occasional disorientation a few weeks
after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in
the kitchen. The home care nurse calls the woman's health care provider to discuss the client's situation
and background, assess, and give recommendations. The nurse concludes that the client most likely has
which problem? - Answer - delirium and a urinary tract infection (UTI)
Delirium is commonly due to a medical condition such as a UTI in the older adult. Delirium often involves
memory problems, disorientation, and hallucinations. It develops rather quickly. There are not enough
data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and
adjusting to being alone are unlikely to cause hallucinations.
, A client has been involuntarily committed to a hospital because he has been assessed as being
dangerous to self or others. The client has lost which right? - Answer - the right to leave the hospital
against medical advice
An involuntarily admitted client loses the right to leave the hospital until the condition is stable enough
that the client no longer poses a danger to self or others. While hospitalized, the client retains all civil
rights such as receiving mail, making phone calls, refusing treatment, and also receiving the least
restrictive treatment. Should the involuntarily admitted client refuse treatment once admitted, he will be
evaluated for the need to receive treatment against wishes in order to decrease the risk for self-harm or
harm to others.
A client who is suspicious of others, including staff, is brought to the hospital wearing a wrinkled dress
with stains on the front. Assessment also reveals a flat affect, confusion, and slow movements. Which
goal should the nurse identify as the initial priority when planning this client's care? - Answer - helping
the client feel safe and accepted
The initial priority for this client is to help her overcome suspiciousness of others, including staff, and
thereby feel safe and accepted. Introducing the client to others, giving the client information about the
program, and providing clean clothes are important, but these are of lower priority than helping the
client feel safe and accepted.
After talking with the nurse, a client admits to being physically abused by her husband. She says that she
has never called the police because her husband has threatened to kill her if she does. She says, "I don't
want to get him into trouble, because he's the father of my children. I don't know what to do!" Which
nursing intervention would be most therapeutic at this time? - Answer - Express concern for the client's
safety.
The nurse's expression of concern for the client's safety may help the client validate her fears and choose
to take action.
Talking to the client about changing her behavior is a form of victim blaming and reinforces the message
that the client is responsible for the abuse. She is likely getting the same message from the abuser and
others.
Talking to the client about reducing family stress is also a form of victim blaming.
Telling the client to leave her husband is inappropriate advice. The idea of leaving the marriage may be
so overwhelming that it may push the client away from the nurse as a support person.
