ANSWERS AND RATIONALE (70 QUESTIONS)
Question 1
A nurse is admitting a client with schizophrenia who states, “I’m hearing voices.” Which response is
the nurse’s priority?
A. “What are the voices telling you?”
B. “I realize the voices are real to you, but I don’t hear anything.”
C. “Have you taken your medication today?”
D. “How long have you been hearing the voices?”
Answer: A
Rationale: The priority is assessing the content of the voices to identify potential commands for
self-harm or harm to others, ensuring immediate safety. Acknowledging the client’s reality (B) is
therapeutic but less urgent, while medication compliance (C) and duration of symptoms (D) are
secondary to assessing risk.
Question 2
A nurse is caring for a client in seclusion to prevent harm to others. Which action is appropriate?
A. Document the client’s behavior prior to seclusion.
,B. Assess the client’s behavior once every hour.
C. Offer fluids every 2 hours.
D. Discuss the client’s inappropriate behavior prior to seclusion.
Answer: A
Rationale: Documenting the behavior justifying seclusion is critical for legal and ethical
accountability. Assessments (B) are typically more frequent (every 15–30 minutes per policy),
fluids (C) are offered based on need, and discussing behavior (D) is inappropriate during acute
agitation.
Question 3
A parish nurse is leading a support group for clients whose family members died by suicide. Which
strategy should the nurse use?
A. Encourage clients to establish a timeline for grieving.
B. Initiate a discussion about coping with family dynamic changes.
C. Assist clients in identifying ways suicide could have been prevented.
D. Discourage sharing negative aspects of their relationship with the deceased.
Answer: B
,Rationale: Discussing coping strategies for family dynamic changes promotes emotional processing
and resilience. Timelines (A) may pressure clients, focusing on prevention (C) can increase guilt,
and discouraging negative sharing (D) stifles authentic expression.
Question 4
A nurse is planning care for an older adult with dementia. Which interventions should be included?
(Select all that apply.)
A. Give one simple direction at a time.
B. Refute the client’s delusions using logic.
C. Allow the client to choose among a variety of activities each day.
D. Reinforce orientation to time, place, and person.
E. Establish eye contact when communicating.
Answer: A, D, E
Rationale: Simple directions (A) reduce confusion, orientation reinforcement (D) grounds the client
in reality, and eye contact (E) enhances communication. Refuting delusions (B) may increase
agitation, and multiple activity choices (C) can overwhelm clients with dementia.
Question 5
A client undergoing psychotherapy requests the therapist’s notes. Which response should the nurse
make?
, A. “Are you not happy with your treatment?”
B. “We can provide a copy of your records, but the therapist’s notes are not included.”
C. “Why are you interested in seeing your therapist’s notes?”
D. “I don’t think you will benefit from reviewing your therapist’s notes right now.”
Answer: B
Rationale: Therapist notes are confidential and excluded from client-accessible records under
HIPAA. Questioning satisfaction (A) or motives (C) is dismissive, and denying benefit (D) is
judgmental and non-therapeutic.
Question 6
A client in the ED reports being beaten and sexually assaulted by her partner. After a rapid
assessment, what should the nurse do next?
A. Conduct a pregnancy test.
B. Request a mental health consultation.
C. Provide a trained advocate to stay with the client.
D. Offer prophylactic medication for STIs.
Answer: C