and Answers | Latest Version | 2025/2026
| Correct & Verified
What is the first action a nurse should take when a client begins pacing and clenching their fists?
✔✔ Assess the client for escalating agitation and ensure safety
What is the primary goal during the orientation phase of a therapeutic nurse-client relationship?
✔✔ To establish trust and define the roles and boundaries
What is the best response for a nurse to give when a client says, “I feel like giving up”?
✔✔ “Can you tell me more about what you’re feeling right now?”
A client with depression states, “I’m worthless.” What is the most therapeutic response?
✔✔ “It sounds like you’re feeling very down on yourself. Let’s talk about that.”
What should the nurse do first when a client expresses thoughts of self-harm?
✔✔ Ask the client if they have a specific plan and the means to carry it out
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,During a group session, a client begins yelling and threatening others. What is the nurse’s
immediate priority?
✔✔ Remove the client from the group to de-escalate the situation
What behavior indicates that a client is in the working phase of the therapeutic relationship?
✔✔ The client discusses painful memories and begins to problem-solve
A client with schizophrenia says, “The television is talking to me.” What is the best nursing
response?
✔✔ “That must be very unsettling. What is the television saying to you?”
A nurse hears a client crying softly in their room. What is the best initial action?
✔✔ Knock gently and ask, “Would you like to talk about what’s bothering you?”
A nurse is caring for a client newly admitted for major depressive disorder. What is the priority
assessment?
✔✔ Evaluate the client’s risk for self-harm or suicide
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, What is an appropriate nursing response when a client with PTSD avoids discussing a traumatic
event?
✔✔ “I understand that talking about this is hard. We can go at your pace.”
A client in the manic phase of bipolar disorder is interrupting others and becoming increasingly
loud. What should the nurse do?
✔✔ Calmly escort the client to a quiet room for redirection
What is the nurse's responsibility if a client reports abuse by a caregiver?
✔✔ Report the allegation according to facility protocol and local law
What is a sign that a client is progressing in treatment for anxiety?
✔✔ The client verbalizes coping strategies and practices relaxation techniques
A client is experiencing command hallucinations. What is the most important nursing action?
✔✔ Ask the client what the voices are telling them to do
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