,NSG 221 Mental Health Exam 2 | Herzing
University | Latest 2026/2027 Updated (PDF)
1. A client who recently lost their spouse in a motor vehicle accident tells the nurse, "I keep expecting
them to walk through the door. This can't be real." The nurse recognizes this statement as most
consistent with which stage of grief according to Kubler-Ross?
A) Anger
B) Bargaining
C) Denial
D) Depression
Correct Answer: Denial
Rationale: Denial is characterized by shock and disbelief regarding the loss, serving as a psychological
cushion to protect the individual from overwhelming stress. The client's statement about expecting
the spouse to return reflects this protective mechanism. Anger involves expression toward others,
bargaining involves attempts to delay the inevitable, and depression involves acute awareness of the
loss.
2. A nurse is caring for a client who is exhibiting signs of alcohol withdrawal. Which assessment
finding requires the nurse's immediate priority intervention?
A) Diaphoresis and mild tachycardia
B) Nausea and occasional vomiting
C) Seizure activity and severe confusion
D) Insomnia and mild anxiety
Correct Answer: Seizure activity and severe confusion
Rationale: Seizure activity and severe confusion indicate severe alcohol withdrawal, which can
progress to delirium tremens and is life-threatening. Diaphoresis, tachycardia, nausea, vomiting,
insomnia, and mild anxiety are also withdrawal symptoms but do not represent the same level of
imminent danger. Seizure activity requires immediate medical intervention to prevent further
complications.
,3. A client diagnosed with Oppositional Defiant Disorder (ODD) is being assessed by the nurse. Which
characteristic is most consistent with this diagnosis?
A) Deficiencies in attention, flexibility of thinking, and decision making
B) Persistent disregard for the rights of others and violation of societal norms
C) Severe impairment in social interaction and communication
D) Recurrent, intrusive thoughts and repetitive behaviors
Correct Answer: Deficiencies in attention, flexibility of thinking, and decision making
Rationale: Children with ODD demonstrate impaired problem-solving abilities and deficiencies in
attention, flexibility of thinking, and decision making. They also have lower self-concept and lack of
competence in social situations. Persistent disregard for others' rights is characteristic of conduct
disorder, social interaction impairment suggests autism spectrum, and intrusive thoughts suggest
OCD.
4. A client experiencing a panic attack tells the nurse, "I feel like I'm going to die. My heart is racing
and I can't breathe." Which nursing intervention should the nurse implement first?
A) Ask the client to describe what triggered the panic attack
B) Administer a PRN benzodiazepine as ordered
C) Help the client use grounding and breathing techniques
D) Explain the physiologic basis of the panic response
Correct Answer: Help the client use grounding and breathing techniques
Rationale: During a panic attack, the priority is to help the client regain control through grounding and
focused breathing techniques. These interventions address the immediate physiologic and emotional
distress. Exploring triggers, administering medication, or providing explanations are not the first-line
interventions during the acute episode, as the client's cognitive processing is impaired.
5. A client who is grieving the loss of a child states, "If I had just been more careful, this never would
have happened." The nurse recognizes this statement as reflecting which type of response to grief?
, A) Cognitive response
B) Emotional response
C) Behavioral response
D) Spiritual response
Correct Answer: Emotional response
Rationale: Guilt is a predominant emotional response to loss. The client's self-blame reflects the
emotional dimension of grieving. Cognitive responses involve questioning and trying to make sense of
the loss, behavioral responses include observable actions like crying or restlessness, and spiritual
responses involve disillusionment with God or meaninglessness.
6. A client with a history of alcohol use disorder is prescribed Disulfiram (Antabuse). Which statement
by the client indicates correct understanding of this medication?
A) "I can drink small amounts of alcohol while taking this medication."
B) "This medication will reduce my craving for alcohol over time."
C) "Drinking alcohol while taking this medication will make me very sick."
D) "This medication works by blocking the euphoric effects of alcohol."
Correct Answer: "Drinking alcohol while taking this medication will make me very sick."
Rationale: Disulfiram produces an unpleasant reaction when combined with alcohol, including nausea,
vomiting, flushing, and palpitations, serving as a deterrent. It does not reduce cravings (naltrexone
addresses cravings), and any alcohol consumption while taking it will trigger the adverse reaction. The
medication works by inhibiting aldehyde dehydrogenase, not by blocking euphoric effects.
7. According to Engel's stages of loss, a client who is crying, expressing feelings of helplessness, and
directing anger toward self or others is most likely in which stage?
A) Shock and disbelief
B) Developing awareness
C) Restitution
D) Recovery
University | Latest 2026/2027 Updated (PDF)
1. A client who recently lost their spouse in a motor vehicle accident tells the nurse, "I keep expecting
them to walk through the door. This can't be real." The nurse recognizes this statement as most
consistent with which stage of grief according to Kubler-Ross?
A) Anger
B) Bargaining
C) Denial
D) Depression
Correct Answer: Denial
Rationale: Denial is characterized by shock and disbelief regarding the loss, serving as a psychological
cushion to protect the individual from overwhelming stress. The client's statement about expecting
the spouse to return reflects this protective mechanism. Anger involves expression toward others,
bargaining involves attempts to delay the inevitable, and depression involves acute awareness of the
loss.
2. A nurse is caring for a client who is exhibiting signs of alcohol withdrawal. Which assessment
finding requires the nurse's immediate priority intervention?
A) Diaphoresis and mild tachycardia
B) Nausea and occasional vomiting
C) Seizure activity and severe confusion
D) Insomnia and mild anxiety
Correct Answer: Seizure activity and severe confusion
Rationale: Seizure activity and severe confusion indicate severe alcohol withdrawal, which can
progress to delirium tremens and is life-threatening. Diaphoresis, tachycardia, nausea, vomiting,
insomnia, and mild anxiety are also withdrawal symptoms but do not represent the same level of
imminent danger. Seizure activity requires immediate medical intervention to prevent further
complications.
,3. A client diagnosed with Oppositional Defiant Disorder (ODD) is being assessed by the nurse. Which
characteristic is most consistent with this diagnosis?
A) Deficiencies in attention, flexibility of thinking, and decision making
B) Persistent disregard for the rights of others and violation of societal norms
C) Severe impairment in social interaction and communication
D) Recurrent, intrusive thoughts and repetitive behaviors
Correct Answer: Deficiencies in attention, flexibility of thinking, and decision making
Rationale: Children with ODD demonstrate impaired problem-solving abilities and deficiencies in
attention, flexibility of thinking, and decision making. They also have lower self-concept and lack of
competence in social situations. Persistent disregard for others' rights is characteristic of conduct
disorder, social interaction impairment suggests autism spectrum, and intrusive thoughts suggest
OCD.
4. A client experiencing a panic attack tells the nurse, "I feel like I'm going to die. My heart is racing
and I can't breathe." Which nursing intervention should the nurse implement first?
A) Ask the client to describe what triggered the panic attack
B) Administer a PRN benzodiazepine as ordered
C) Help the client use grounding and breathing techniques
D) Explain the physiologic basis of the panic response
Correct Answer: Help the client use grounding and breathing techniques
Rationale: During a panic attack, the priority is to help the client regain control through grounding and
focused breathing techniques. These interventions address the immediate physiologic and emotional
distress. Exploring triggers, administering medication, or providing explanations are not the first-line
interventions during the acute episode, as the client's cognitive processing is impaired.
5. A client who is grieving the loss of a child states, "If I had just been more careful, this never would
have happened." The nurse recognizes this statement as reflecting which type of response to grief?
, A) Cognitive response
B) Emotional response
C) Behavioral response
D) Spiritual response
Correct Answer: Emotional response
Rationale: Guilt is a predominant emotional response to loss. The client's self-blame reflects the
emotional dimension of grieving. Cognitive responses involve questioning and trying to make sense of
the loss, behavioral responses include observable actions like crying or restlessness, and spiritual
responses involve disillusionment with God or meaninglessness.
6. A client with a history of alcohol use disorder is prescribed Disulfiram (Antabuse). Which statement
by the client indicates correct understanding of this medication?
A) "I can drink small amounts of alcohol while taking this medication."
B) "This medication will reduce my craving for alcohol over time."
C) "Drinking alcohol while taking this medication will make me very sick."
D) "This medication works by blocking the euphoric effects of alcohol."
Correct Answer: "Drinking alcohol while taking this medication will make me very sick."
Rationale: Disulfiram produces an unpleasant reaction when combined with alcohol, including nausea,
vomiting, flushing, and palpitations, serving as a deterrent. It does not reduce cravings (naltrexone
addresses cravings), and any alcohol consumption while taking it will trigger the adverse reaction. The
medication works by inhibiting aldehyde dehydrogenase, not by blocking euphoric effects.
7. According to Engel's stages of loss, a client who is crying, expressing feelings of helplessness, and
directing anger toward self or others is most likely in which stage?
A) Shock and disbelief
B) Developing awareness
C) Restitution
D) Recovery
