2025/2026 (Version A & B) with Actual
Exam Questions and Correct Answers
with Rationales | Graded A+
Question 1 Depressed client stays in bed all day and refuses meals. Highest priority? Answer:
Imbalanced nutrition: less than body requirements Rationale: Physiological needs come first
(Maslow); untreated malnutrition can kill quickly in depression.
Question 2 Client yells, “My roommate is the most selfish, angry jerk ever!” Defense
mechanism? Answer: Projection Rationale: Client is putting his own unacceptable anger onto
the roommate.
Question 3 Sexual assault victim is calm and quiet in the ED. Defense mechanism? Answer:
Denial Rationale: Common acute trauma response – emotionally blocking the event.
Question 4 Schizophrenic client hears voices. Most important question? Answer: “Do the
voices tell you to hurt yourself or anyone else?” Rationale: Command hallucinations =
immediate safety risk.
Question 5 Client on lithium has nausea, vomiting, coarse tremor. Priority action? Answer:
Obtain lithium level stat Rationale: Early signs of toxicity (therapeutic 0.6–1.2 mEq/L).
Question 6 MHW maintains constant eye contact with escalating client. RN intervenes because:
Answer: Constant eye contact can be perceived as threatening Rationale: Escalates agitation;
use minimal eye contact for de-escalation.
Question 7 Dying client: “I’m angry my family keeps hoping for a cure.” Best response?
Answer: “Have you shared these feelings with your family?” Rationale: Encourages open
family communication.
Question 8 Rape victim in ED. Most important evidence question? Answer: “Have you
showered, douched, or changed clothes?” Rationale: These destroy forensic evidence.
Question 9 Best sign a grieving client is coping effectively? Answer: Attends bereavement
support group Rationale: Active engagement = adaptive coping.
Question 10 Borderline client threatens self-harm in group. First action? Answer: Assess
lethality and current intent Rationale: Drives all further safety interventions.