Click here for more: Scholars nexus
Focus on Mental Health Exam Questions with Detailed
Verified Answers
A nurse overhears a hospitalized client with mania telling another client, "I'm actually a journalist
writing an article for a magazine — I'm just posing as a person with mental illness." How should the
nurse respond? Ans: ✓ ✓ ✓ Presenting the client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that
the nurse does not share the client's perceptions. All three of the other options — ignoring the
delusion, taking the client to a quiet room, and supporting the client's denial of illness — do not
focus on reality, and they ignore the issue. Presenting the client with the actual situation helps
orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get out." How
should the nurse respond to the client? Ans: ✓ ✓ ✓ "I know you must be very upset by this, but I
don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate
the client's experience, because this may lead to a regressive struggle with the client. Giving advice
or false reassurance is incorrect because such techniques indicate that demons actually are present,
which feeds into the client's hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for picking the
neighbors' flowers." Which defense mechanism was the child using? Ans: ✓ ✓ ✓ Displacement
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for
one person onto a less threatening substitute person or object to satisfy an impulse. Projection
involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in
blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable
object. Identification involves modeling behavior after someone else's.
© Get it right 2025 Getaway - Stuvia US All rights reserved
,Click here for more: Scholars nexus
A client says to the nurse, "Even though my husband and I keep telling them we don't want to have
children, our parents are pressuring us to 'start a family.' What should we say to them?" Which of
the following responses by the nurse is therapeutic? Ans: ✓ ✓ ✓ "This must be very difficult for
both of you."
Rationale: Childless families may elect not to have children or to postpone having them until they
have established themselves occupationally or financially. Telling the client to tell the parents that
the couple can't have children is incorrect because the client is being encouraged to lie about life
decisions rather than helping the parents understand the couple's choices. Asking how they usually
cope with such interference is incorrect because it indicates that the nurse is judgmental and has
decided that the parents are interfering with the client and spouse. Saying, "Tell them to have more
children if they want them so badly," is incorrect because it is sarcastic and ridicules the situation
over which the client has expressed concerns.
A young adult client says, "I just can't seem to stop snapping at my parents. I know they work hard
to support me, but what do I do when they're so overbearing?" Which responses by the nurse is
therapeutic? Ans: ✓ ✓ ✓ "Have you talked to your parents about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages the therapeutic
technique of formulating a plan of action. "It's important not to be rude to your parents" and "You
need to be more patient with your parents" are both nontherapeutic, judgmental responses that do
not encourage the client to further explore her feelings and problem-solve. "Snapping at your
parents is childish. How could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
A client says, "I have so much trouble caring for my husband's child from his first marriage. I resent
the money we have to pay for child support because we have to deprive my own child of things.
How can I stop feeling this way?" Which response by the nurse is therapeutic? Ans: ✓ ✓ ✓ "Have
you shared your feelings with your husband?"
Rationale: Remarried individuals often encounter problems as a result of the stressors they bring
into a marriage without prior discussion with the new partner. Bonding sometimes does always
occur when a child is not one's biological offspring. The correct answer is focused on the client's
feelings. "Your child benefits from having a sibling" is not facilitative. "I wonder why you married
him, knowing that he wouldn't desert his biological child" is incorrect because it prejudges the
© Get it right 2025 Getaway - Stuvia US All rights reserved
,Click here for more: Scholars nexus
client. "You need to take a second job to give your child what you think she deserves" is not open
ended, does not facilitate feelings, and gives advice.
A client says to the nurse, "My wife retired last year from a lucrative law practice, and I'm really
discouraged. I'll be working until I die, even though I helped pay for her education." Which response
by the nurse is supportive? Ans: ✓ ✓ ✓ "You sound very troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to
express his feelings; nor does "That's such a tough break for you." Suggesting that the husband
approach the spouse for help is incorrect because it prematurely gives advice, a nontherapeutic
communication technique. The correct option is focused on the client's feelings.
A gay man is brought to the emergency department by the police. The client tells the nurse, "I was
beaten up. I guess I just have to expect this kind of treatment for the rest of my life." Which
statement by the nurse is therapeutic? Ans: ✓ ✓ ✓ "You feel that being beaten up goes along with
being gay?"
Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. "I
think you should take some self-defense classes" is incorrect because it advises the client, and
giving advice is not therapeutic. "Maybe you should be more discreet when you're in public" also
gives advice and presumes that the client has been indiscreet. "Why not try counseling to change
your sexual orientation?" is incorrect because it assumes that sexual orientation can or should be
changed. The correct option indicates reflection and is focused on the client's feelings.
A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has
priority in the plan of care? Ans: ✓ ✓ ✓ Assessing the client's risk for violence toward self and
others
Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the
client's risk for violence toward self and others. Although the nurse will assist the client in resolving
the grief and monitor the client's sleep pattern, these are not the priority interventions of the
options given. Obtaining a prescription for an antidepressant is not a priority.
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is
experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client?
Select all that apply. Ans: ✓ ✓ ✓ Assisting the client in verbalizing fears
© Get it right 2025 Getaway - Stuvia US All rights reserved
, Click here for more: Scholars nexus
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
Rationale: Assisting the client with problem-solving and decision-making, helping the client
verbalize fears, helping the client identify sources of hope, and monitoring the client for signs of
self-harm are all appropriate interventions. In planning care for a client having difficulty adjusting to
an illness, the nurse develops interventions to promote social networking that will provide needed
support and information to the client.
An emergency department nurse is caring for an older client who is a victim of physical abuse. List
in order of priority the following nursing actions, with number 1 representing the first action and
number 4 the last. Ans: ✓ ✓ ✓ 1. Checking the client for physical injuries
2. Contacting the appropriate state officials to report the abuse
3. Contacting a social worker to assist in planning care for the client
4. Calling a member of the clergy to address the client's spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the client for physical
injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The
next action is to contact the social worker to obtain assistance in planning care for the client. The
client may need the social worker's help with housing as well. Last, a referral to a member of the
clergy is an appropriate intervention if the client desires it.
The parents of an 18-month-old arrive at the emergency department with their unconscious child.
Physical examination reveals bruises on the child's upper arms that resemble grip marks. Which
nursing intervention is the priority? Ans: ✓ ✓ ✓ Stabilizing the child's physical condition
Rationale: In all child abuse cases, the primary concern is the physical condition of the child.
Although contacting appropriate state officials to report suspected abuse and securing a safe
environment for the child are both interventions that need to be performed, this child is
unconscious, so the priority is to stabilize the child's physical condition. Confronting the parents
© Get it right 2025 Getaway - Stuvia US All rights reserved
Focus on Mental Health Exam Questions with Detailed
Verified Answers
A nurse overhears a hospitalized client with mania telling another client, "I'm actually a journalist
writing an article for a magazine — I'm just posing as a person with mental illness." How should the
nurse respond? Ans: ✓ ✓ ✓ Presenting the client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that
the nurse does not share the client's perceptions. All three of the other options — ignoring the
delusion, taking the client to a quiet room, and supporting the client's denial of illness — do not
focus on reality, and they ignore the issue. Presenting the client with the actual situation helps
orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get out." How
should the nurse respond to the client? Ans: ✓ ✓ ✓ "I know you must be very upset by this, but I
don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate
the client's experience, because this may lead to a regressive struggle with the client. Giving advice
or false reassurance is incorrect because such techniques indicate that demons actually are present,
which feeds into the client's hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for picking the
neighbors' flowers." Which defense mechanism was the child using? Ans: ✓ ✓ ✓ Displacement
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for
one person onto a less threatening substitute person or object to satisfy an impulse. Projection
involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in
blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable
object. Identification involves modeling behavior after someone else's.
© Get it right 2025 Getaway - Stuvia US All rights reserved
,Click here for more: Scholars nexus
A client says to the nurse, "Even though my husband and I keep telling them we don't want to have
children, our parents are pressuring us to 'start a family.' What should we say to them?" Which of
the following responses by the nurse is therapeutic? Ans: ✓ ✓ ✓ "This must be very difficult for
both of you."
Rationale: Childless families may elect not to have children or to postpone having them until they
have established themselves occupationally or financially. Telling the client to tell the parents that
the couple can't have children is incorrect because the client is being encouraged to lie about life
decisions rather than helping the parents understand the couple's choices. Asking how they usually
cope with such interference is incorrect because it indicates that the nurse is judgmental and has
decided that the parents are interfering with the client and spouse. Saying, "Tell them to have more
children if they want them so badly," is incorrect because it is sarcastic and ridicules the situation
over which the client has expressed concerns.
A young adult client says, "I just can't seem to stop snapping at my parents. I know they work hard
to support me, but what do I do when they're so overbearing?" Which responses by the nurse is
therapeutic? Ans: ✓ ✓ ✓ "Have you talked to your parents about your frustrations?"
Rationale: The correct response is focused on the client's concerns and encourages the therapeutic
technique of formulating a plan of action. "It's important not to be rude to your parents" and "You
need to be more patient with your parents" are both nontherapeutic, judgmental responses that do
not encourage the client to further explore her feelings and problem-solve. "Snapping at your
parents is childish. How could you?" is incorrect because it is sarcastic and condescending, which is
nontherapeutic.
A client says, "I have so much trouble caring for my husband's child from his first marriage. I resent
the money we have to pay for child support because we have to deprive my own child of things.
How can I stop feeling this way?" Which response by the nurse is therapeutic? Ans: ✓ ✓ ✓ "Have
you shared your feelings with your husband?"
Rationale: Remarried individuals often encounter problems as a result of the stressors they bring
into a marriage without prior discussion with the new partner. Bonding sometimes does always
occur when a child is not one's biological offspring. The correct answer is focused on the client's
feelings. "Your child benefits from having a sibling" is not facilitative. "I wonder why you married
him, knowing that he wouldn't desert his biological child" is incorrect because it prejudges the
© Get it right 2025 Getaway - Stuvia US All rights reserved
,Click here for more: Scholars nexus
client. "You need to take a second job to give your child what you think she deserves" is not open
ended, does not facilitate feelings, and gives advice.
A client says to the nurse, "My wife retired last year from a lucrative law practice, and I'm really
discouraged. I'll be working until I die, even though I helped pay for her education." Which response
by the nurse is supportive? Ans: ✓ ✓ ✓ "You sound very troubled by this."
Rationale: Saying that the situation is unfair is judgmental and does not encourage the client to
express his feelings; nor does "That's such a tough break for you." Suggesting that the husband
approach the spouse for help is incorrect because it prematurely gives advice, a nontherapeutic
communication technique. The correct option is focused on the client's feelings.
A gay man is brought to the emergency department by the police. The client tells the nurse, "I was
beaten up. I guess I just have to expect this kind of treatment for the rest of my life." Which
statement by the nurse is therapeutic? Ans: ✓ ✓ ✓ "You feel that being beaten up goes along with
being gay?"
Rationale: Many lesbians and gays encounter harassment or violence in the course of their lives. "I
think you should take some self-defense classes" is incorrect because it advises the client, and
giving advice is not therapeutic. "Maybe you should be more discreet when you're in public" also
gives advice and presumes that the client has been indiscreet. "Why not try counseling to change
your sexual orientation?" is incorrect because it assumes that sexual orientation can or should be
changed. The correct option indicates reflection and is focused on the client's feelings.
A client whose spouse recently died is experiencing dysfunctional grieving. Which intervention has
priority in the plan of care? Ans: ✓ ✓ ✓ Assessing the client's risk for violence toward self and
others
Rationale: The priority intervention for a client with dysfunctional grieving is assessment of the
client's risk for violence toward self and others. Although the nurse will assist the client in resolving
the grief and monitor the client's sleep pattern, these are not the priority interventions of the
options given. Obtaining a prescription for an antidepressant is not a priority.
A nurse develops a plan of care for a client in whom AIDS was recently diagnosed. The client is
experiencing difficulty adjusting to the illness. Which interventions are appropriate for this client?
Select all that apply. Ans: ✓ ✓ ✓ Assisting the client in verbalizing fears
© Get it right 2025 Getaway - Stuvia US All rights reserved
, Click here for more: Scholars nexus
Helping the client identify sources of hope
Monitoring the client for signs of self-harm
Assisting the client with problem-solving and decision-making
Rationale: Assisting the client with problem-solving and decision-making, helping the client
verbalize fears, helping the client identify sources of hope, and monitoring the client for signs of
self-harm are all appropriate interventions. In planning care for a client having difficulty adjusting to
an illness, the nurse develops interventions to promote social networking that will provide needed
support and information to the client.
An emergency department nurse is caring for an older client who is a victim of physical abuse. List
in order of priority the following nursing actions, with number 1 representing the first action and
number 4 the last. Ans: ✓ ✓ ✓ 1. Checking the client for physical injuries
2. Contacting the appropriate state officials to report the abuse
3. Contacting a social worker to assist in planning care for the client
4. Calling a member of the clergy to address the client's spiritual needs
Rationale: The priority intervention in the event of physical abuse is to check the client for physical
injuries. The nurse should then fulfill the legal obligation of reporting suspected elder abuse. The
next action is to contact the social worker to obtain assistance in planning care for the client. The
client may need the social worker's help with housing as well. Last, a referral to a member of the
clergy is an appropriate intervention if the client desires it.
The parents of an 18-month-old arrive at the emergency department with their unconscious child.
Physical examination reveals bruises on the child's upper arms that resemble grip marks. Which
nursing intervention is the priority? Ans: ✓ ✓ ✓ Stabilizing the child's physical condition
Rationale: In all child abuse cases, the primary concern is the physical condition of the child.
Although contacting appropriate state officials to report suspected abuse and securing a safe
environment for the child are both interventions that need to be performed, this child is
unconscious, so the priority is to stabilize the child's physical condition. Confronting the parents
© Get it right 2025 Getaway - Stuvia US All rights reserved
