Question 1

Exposure and Response Prevention (ERP) is a part of?

Accepted Answer

Answer reason: Exposure and Response Prevention (ERP) is a behavioral therapy technique that is a core component of cognitive behavioral therapy (CBT), particularly for obsessive-compulsive disorder. It involves systematic exposure to anxiety-provoking stimuli while preventing the usual compulsive response, facilitating habituation and inhibitory learning. Group or family therapy can incorporate CBT strategies, but ERP itself is specifically categorized within CBT interventions. Psychoanalysis is insight-oriented and does not use structured exposure/response prevention protocols.

Question 2

A client with Alzheimer’s disease wanders from room to room moving the belongings of other clients to different locations. Alert and oriented clients are angry that their things have been moved. The nurse aide SHOULD?

Accepted Answer

Answer reason: The immediate nursing aide priority is to address the conflict and restore clients’ property by locating and returning the missing items. Closing the client in a room is inappropriate and unsafe (restraints/false imprisonment risk) and does not address others’ concerns. Walking with the client continuously may be unrealistic as a primary response and does not correct the immediate problem. Reassurance alone does not resolve the tangible issue of missing belongings that is driving the other clients’ distress.

Question 3

Which method should teachers use in the classroom to promote this student’s ability to transition from one classroom activity to another?

Accepted Answer

Answer reason: Visual supports and structured schedules (e.g., visual timetables, first-then boards, countdown cues) are evidence-based strategies to reduce anxiety and increase predictability during transitions, especially for students with executive-functioning or autism-related challenges. They externalize the sequence of tasks and provide consistent cues that do not rely on transient verbal directions. Compared with verbal instructions alone, structured visual routines improve independence and decrease problem behaviors during activity changes. Peer support and AAC can be helpful adjuncts, but they are less directly targeted to transition structure than a visual schedule system.

Question 4

Which therapy uses art, music, or dance to help mental health patients?

Accepted Answer

Answer reason: Creative therapy (including art therapy, music therapy, and dance/movement therapy) uses expressive activities to help patients communicate feelings, reduce stress, and improve coping and emotional regulation. These modalities are commonly used as supportive, nonpharmacologic interventions in mental health care. Electrotherapy (e.g., ECT) uses electrical stimulation and is not defined by art/music/dance. Radiation therapy and dialysis treat cancer and renal failure, respectively, not mental health through expressive means.

Question 5

A psychiatric nurse is planning the care for a manic bipolar client. Which actions/interventions are appropriate for this client?

Accepted Answer

Answer reason: Mania is associated with hyperactivity, distractibility, and escalation with excess stimulation, so a low-stimulus environment and reduced exposure to others helps prevent agitation and supports rest. Clear, consistent limit-setting helps manage impulsive or intrusive behaviors and promotes safety for the client and others. Group activities, TV, and caffeine increase stimulation and can worsen insomnia and manic symptoms. Speaking loudly is not therapeutic and can further escalate behavior; communication should be calm, concise, and firm.

Question 6

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress on discharge. She states that her daughter "stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." In helping the mother prepare for her daughter's discharge, the nurse should suggest which?

Accepted Answer

Answer reason: Caffeine and other stimulants can worsen anxiety symptoms and contribute to restlessness, insomnia, and perceived “hyperactivity,” so reducing exposure is a practical, low-risk home intervention. The other choices are overly restrictive and may increase conflict, reduce healthy peer/school support, and impair the teen’s normal developmental needs. Discharge teaching typically emphasizes supportive structure, healthy habits, and minimizing triggers rather than isolating the adolescent.

Question 7

A client with depression reports lack of interest in daily activities. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: Depression commonly causes anergia, poor concentration, and diminished motivation, so setting small, realistic goals promotes success without overwhelming the client. Achievable activities support behavioral activation, improve self-efficacy, and can gradually increase engagement in ADLs. Competitive, complex, or demanding tasks can increase stress and perceived failure, potentially worsening withdrawal. Dismissing the symptom does not provide therapeutic support or promote recovery-oriented coping.

Question 8

Which parenting style worsens sibling rivalry?

Accepted Answer

Answer reason: Showing preference for one child increases perceived inequity and competition for attention, which escalates jealousy and conflict between siblings. It can undermine each child’s self-esteem and provoke acting-out behaviors aimed at regaining parental approval. Consistent, fair expectations and emotionally supportive parenting instead reduce rivalry by promoting security and cooperative interactions.

Question 9

When the nurse has diagnosed a patient is experiencing panic-level anxiety, an intervention that should be implemented immediately is to?

Accepted Answer

Answer reason: In panic-level anxiety, the patient’s ability to process information is severely impaired, so the priority is to decrease environmental input and provide a calm, safe setting. Lowering noise, limiting people, and using simple, brief directions helps reduce escalating fear and supports re-establishing a sense of control. Teaching relaxation is better after the acute panic subsides. Restraints or a “show of force” are not first-line and can worsen agitation unless there is imminent danger and less restrictive measures have failed.

Question 10

It is essential in desensitization for the patient to?

Accepted Answer

Answer reason: Desensitization (systematic desensitization) pairs gradual exposure to an anxiety-provoking stimulus with a relaxation response to reduce conditioned anxiety. Practicing controlled breathing or other relaxation skills helps counter sympathetic arousal so the person can remain in the exposure hierarchy long enough for habituation and extinction to occur. Rapport is helpful but not the essential mechanism of the technique, and exploring unconscious conflicts aligns more with psychodynamic therapy than behavioral desensitization. Anxiolytics may blunt anxiety but are not required and can interfere with learning if relied upon during exposure.

Question 11

The nursing management of anxiety related with post-traumatic stress disorder includes all of the following EXCEPT?

Accepted Answer

Answer reason: Touching can be misinterpreted as threatening or triggering for clients with PTSD, especially when anxiety and hypervigilance are present, and it can escalate distress. Nursing care focuses on maintaining personal space, using calm verbal de-escalation, and offering presence for safety and grounding rather than physical contact. Remaining with the client during high fear and speaking in a soothing tone are appropriate supportive interventions. Encouraging structured activities can be helpful once the client is stable and willing, but physical reassurance via touch is generally avoided unless clearly consented to and therapeutic.

Question 12

Identify the best technique to improve eye to eye contact in children with autism?

Accepted Answer

Answer reason: Using a mirror provides a nonthreatening, structured way to practice attention to faces and gaze without the intensity of direct interpersonal eye contact, which can be aversive for many children with autism. It supports gradual shaping of social-attention skills through visual feedback and reduced social pressure. The other options rely on coercion or repeated commands, which can increase anxiety, reduce engagement, and are less effective than supportive behavioral techniques.

Question 13

Putting a bitter taste on nails biting is an example of?

Accepted Answer

Answer reason: This uses an unpleasant stimulus (bitter taste) paired with an unwanted behavior (nail biting) to reduce the behavior through negative conditioning. The goal is to create an aversive association so the person is less likely to engage in the habit. Flooding and systematic desensitization are exposure-based techniques for anxiety/phobias, and hypnosis is a different therapeutic modality not based on aversive conditioning.

Question 14

The adolescent with a conduct disorder is yelling and having temper tantrums in the common area of a psychiatric unit. Which nursing intervention is most appropriate for reducing the client's angry outbursts?

Accepted Answer

Answer reason: Behavioral limit-setting on inpatient psychiatry aims to decrease reinforcement of maladaptive, attention-seeking behaviors while maintaining safety. With conduct disorder, angry outbursts can be maintained by the secondary gain of attention from staff and peers, so neutral, brief nonresponse to the initial tantrum helps extinguish the behavior. The nurse should pair this with clear expectations and immediate attention/praise for calm, appropriate communication once the client de-escalates. Mimicking is provocative and escalatory, and simply telling the client to stop yelling often increases power struggles rather than improving self-control.

Question 15

Desensitization is a type of the ?

Accepted Answer

Answer reason: It works by gradually and repeatedly exposing a person to an anxiety-provoking stimulus (often paired with relaxation) to reduce avoidance and physiological arousal over time. This makes it a core technique within behavior therapy (and commonly within CBT as an exposure-based method). Psychoanalysis focuses on unconscious conflicts and insight rather than systematic exposure, making it a poor fit compared with behavioral approaches.

Question 16

A nurse is caring for a client who has bulimia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: Bulimia nervosa commonly involves compensatory behaviors (especially self-induced vomiting and laxative/diuretic misuse) immediately after eating, creating significant risks for dehydration, electrolyte disturbances, and cardiac dysrhythmias. Structured supervision after meals and limiting unsupervised bathroom access helps interrupt purging behavior and supports nutritional rehabilitation. A consistent, staff-directed meal plan is safer than allowing the client to set the schedule, which can reinforce restriction/binge cycles. Encouraging frequent exercise can worsen compensatory behaviors and undermine weight-restoration and stabilization goals.

Question 17

Of the following, which often triggers an episode of violence or aggression by the patient with a psychiatric diagnosis that may involve violent behavior?

Accepted Answer

Answer reason: Limit-setting can be experienced as a threat or provocation, especially in patients who are paranoid, intoxicated/withdrawing, manic, or have poor impulse control, triggering agitation and aggression. Clear, consistent boundaries are still necessary, but they should be implemented with calm communication, respect, and early de-escalation strategies to reduce escalation. By contrast, collaborative engagement such as asking for input typically supports autonomy and reduces oppositional behavior, while neutral activities like taking a walk are often used to lower arousal.

Question 18

A client with posttraumatic stress disorder (PTSD) tells the nurse that the client's recent cognitive behavioral therapy has been difficult. The client states that the client's therapist has the client visualize the sights and sounds from the time that the client was assaulted. This client is likely receiving?

Accepted Answer

Answer reason: Exposure-based approaches treat PTSD by systematically confronting trauma-related memories, cues, and sensations in a controlled therapeutic setting to reduce avoidance and conditioned fear responses. Having the client intentionally visualize the sights and sounds of the assault describes imaginal exposure, a core technique within exposure therapy. Over repeated sessions, this process supports habituation and new learning that the memory and associated cues are not currently dangerous. In contrast, cognitive processing therapy and cognitive restructuring focus primarily on identifying and modifying maladaptive beliefs (eg, guilt, self-blame), and stress inoculation training emphasizes coping skills (eg, relaxation) rather than direct reliving of the trauma narrative.

Question 19

Prior to giving a hospitalized pre-schooler an injection, the nurse gives the child's teddy bear a "shot" first. This method of acting out situations that are part of the hospital experience is known as?

Accepted Answer

Answer reason: Giving the teddy bear a “shot” allows the child to act out the medical experience in a safe, symbolic way and rehearse what will happen to them. This is a classic therapeutic technique used to reduce anxiety and improve cooperation by normalizing the event. Diversionary activity mainly distracts without processing the event, while role play is broader and not as specifically tied to imaginative reenactment typical of preschool development.

Question 20

Which of the following is an appropriate tension-reduction intervention for the patient who may be escalating toward aggressive behavior?

Accepted Answer

Answer reason: Offering the patient choices that support coping—seeking supportive verbal contact, having time alone to decompress, or using calming sensory input like music—can reduce agitation and perceived threat. These interventions are generally low-risk and can be tailored to the patient’s preferences, which improves collaboration and preserves dignity. A common pitfall is forcing interaction when the patient is overstimulated, which can intensify agitation rather than relieve it.

Question 21

A client has been diagnosed with posttraumatic stress disorder (PTSD) after witnessing an explosion at the client's industrial worksite. The client will soon begin exposure therapy, so the nurse should prepare the client for?

Accepted Answer

Answer reason: Exposure therapy is a behavioral treatment that reduces PTSD symptoms by systematically and safely confronting trauma-related cues to extinguish conditioned fear and avoidance. Visiting the trauma-associated site with a therapist is a classic form of in-vivo exposure done with support, pacing, and coping skills to prevent overwhelm. This directly targets avoidance and re-experiencing by allowing new learning that the cues are not currently dangerous. A family meeting or support group may provide support but does not constitute structured exposure, and general reflection on life impact aligns more with cognitive processing than exposure itself.

Question 22

A client was admitted to the psychiatric unit with a diagnosis of bipolar disorder. He constantly bothers other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity would be best for the client?

Accepted Answer

Answer reason: A simple physical activity helps channel excess motor activity, reduce agitation, and provides an appropriate focus without requiring prolonged concentration. This choice also supports brief, goal-directed engagement that can be redirected easily by staff. In contrast, sedentary or cognitively demanding activities often exceed attention span in mania and can worsen frustration and restlessness. Providing an outlet for energy while maintaining structure helps decrease intrusive interactions with others on the unit.

Question 23

The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do first?

Accepted Answer

Answer reason: Allowing the child to touch and explore the cuff and equipment first uses play and desensitization to reduce anxiety and improve cooperation. This approach also supports a smoother, safer measurement by decreasing movement and resistance. In contrast, verbal explanations about health benefits or cardiac function are developmentally less meaningful and are less effective as an initial step.

Question 24

A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time?

Accepted Answer

Answer reason: A low-stimulation setting decreases triggers, helps the client focus on communication, and lowers the likelihood of escalating behavior in a busy ED. Allowing unrestricted wandering increases safety risks and disrupts care, while assigning a focus-demanding activity is unrealistic when attention is impaired. Immediate secure isolation is generally reserved for situations with imminent danger or failed less-restrictive measures, so a quieter room is the safest least-restrictive first step.

Question 25

The client with mania is skipping up and down the hallway, nearly running into other clients. The nurse should include which activity in the client's plan of care?

Accepted Answer

Answer reason: A simple, concrete task that uses excess energy and has clear limits helps decrease pacing and risk of collision while promoting some focus. Activities requiring sustained concentration or stimulation can worsen distractibility and increase agitation. Group-leading increases social stimulation and demands organization, which can escalate manic behavior and undermine safety.

Question 26

A client with antisocial personality disorder suddenly gets angry at the nurse for not being allowed in the staff lounge. How does the nurse respond?

Accepted Answer

Answer reason: Clients with antisocial personality disorder commonly test limits and may escalate when boundaries are inconsistent, so the therapeutic priority is clear, consistent limit-setting to maintain safety and structure. A calm, firm response avoids power struggles while communicating expectations and consequences in a nonpunitive way. Redirection provides an immediate, safer outlet for agitation and reduces reinforcement of aggressive behavior. By contrast, therapeutic touch can be poorly received or increase risk during escalation, and medication framed as a threat can further provoke or undermine rapport.

Question 27

Which of the following activities are recommended to a patient who becomes anxious when thoughts of suicide occur?

Accepted Answer

Answer reason: This option is low-effort, readily available, and provides rapid attentional shift away from ruminations during a high-distress moment. In contrast, meditation often requires sustained focus and can intensify internal preoccupation in anxious or suicidal clients, and exercise may be unsafe or unrealistic when agitation or impulsivity is present. A straightforward distraction strategy is therefore the best initial recommendation among the choices.

Question 28

The nurse is planning care for a client experiencing a manic episode. Which of the following interventions should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: Mania is marked by heightened arousal and distractibility, so the priority is reducing environmental stimulation to help the client regain behavioral control and decrease escalation risk. A quiet, low-stimulus setting supports de-escalation and promotes rest without requiring complex decision-making from an impulsive, overactive client. Restricting calories is unsafe because manic clients often have poor intake and high activity, increasing dehydration and weight loss risk. Allowing self-directed sleep schedules or unrestricted chosen activities increases overstimulation, poor sleep, and unsafe impulsive behavior.

Question 29

You are caring for a patient with major depression. The patient has become unable to complete her activities of daily living (ADLs). What intervention should the nurse take to help this patient?

Accepted Answer

Answer reason: Major depression commonly causes psychomotor retardation, low energy, impaired concentration, and reduced motivation, so the nurse should structure care to support success with self-care tasks. Allowing extra time and providing a predictable routine promotes independence while preventing the patient from becoming overwhelmed and giving up. Doing all ADLs for the patient can reinforce dependency and reduce opportunities for mastery and recovery-oriented functioning. Punitive consequences or peer confrontation are nontherapeutic, can increase guilt and hopelessness, and may worsen depressive symptoms rather than improve ADL performance.

Question 30

The nurse is planning care for a client with bipolar I disorder who is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care?

Accepted Answer

Answer reason: Mania is characterized by hyperactivity, distractibility, impulsivity, and poor judgment, so nursing care prioritizes reducing environmental stimulation while providing safe, goal-directed outlets. Structured solitary activities (eg, walking with staff, simple puzzles, journaling) channel energy without the added stimulation and conflict potential of groups. This approach also supports limit-setting and decreases the risk of escalation from competition or intrusive interactions. In contrast, group therapy often overstimulates and can worsen agitation and disrupt others, and “confronting” aggression tends to escalate rather than de-escalate behavior.

Question 31

A nurse is caring for an older client who has dementia. The client frequently wanders and becomes agitated during the evening hours. Which nursing intervention is most appropriate for managing the client's agitation and wandering?

Accepted Answer

Answer reason: Agitation and evening wandering in dementia often reflect “sundowning,” where fatigue, reduced stimulation, and disrupted circadian cues worsen confusion later in the day. Structured daytime activity and calming, familiar music help decrease anxiety, support sleep-wake regulation, and reduce excess energy that can drive wandering. Sedatives increase risk for falls, worsening confusion, and paradoxical agitation and are not first-line for behavior management. Restraints are a last resort due to injury risk and can escalate agitation; constant dim lighting can worsen disorientation and sleep disruption.

Question 32

Which therapy may be used with a client who admits to frotage?

Accepted Answer

Answer reason: Behavioral reinforcement strategies help shape alternative, appropriate behaviors and support adherence to treatment goals. Group therapy can provide accountability, skills training, and relapse-prevention strategies, while addressing distorted beliefs and social skills deficits. ECT is not an indicated treatment for paraphilic behaviors, and medications may be adjunctive in selected cases (e.g., severe impulsivity or comorbid conditions) but are not the primary therapy being tested here.

Question 33

What is the most appropriate action for a nurse to implement when caring for a client who is having a delusion?

Accepted Answer

Answer reason: The key nursing principle with delusions is to avoid validating the false belief while providing reality-based structure and reducing escalation risk. Structured, goal-directed activities can decrease preoccupation with the delusional content, lower anxiety, and support functioning without confronting the belief head-on. Directly challenging a delusion often increases defensiveness, mistrust, and agitation, worsening therapeutic rapport and safety. Similarly, acting as though the belief is true reinforces the psychosis and can deepen the delusional system. Brief acknowledgment of feelings with redirection to a concrete activity is typically the safest, most therapeutic approach.

Question 34

Which nursing intervention is important for a client who engages in sexual acts with animals (zoophilia)?

Accepted Answer

Answer reason: Behavioral interventions start with a functional assessment to identify antecedents, thoughts, emotions, and situations that precipitate the behavior, because this guides targeted coping strategies and risk-reduction planning. Understanding triggers helps the nurse collaborate on safer alternative behaviors, stimulus control, and referral for specialized psychotherapy, while also assessing for coercion, comorbidities, and safety risks. Seclusion is an emergency measure reserved for immediate danger and is not a primary intervention for paraphilic behavior in the absence of acute violence. Medication is not first-line unless treating a diagnosed comorbid condition or using specific antiandrogen/SSRI strategies under specialist direction, and advising secrecy undermines therapeutic communication and appropriate treatment engagement.

Question 35

Which nursing intervention is appropriate for a client diagnosed with a somatoform pain disorder?

Accepted Answer

Answer reason: Somatic symptom–related pain is managed by minimizing reinforcement of symptom-focused behaviors while promoting adaptive functioning and coping. Providing attention and validation for wellness behaviors helps reduce secondary gain and shifts the client toward normal roles and activity. This approach supports consistent limit-setting (e.g., brief, scheduled assessments) while maintaining a therapeutic relationship and acknowledging that the pain experience feels real to the client. Options focused on body image, relief of fear, or recovery of lost function align more with other conditions (e.g., body dysmorphic concerns, illness anxiety, conversion disorder) rather than somatoform pain disorder management.

Question 36

A nurse is working with parents of an adolescent client who abuses inhalants. What is the most important information for the nurse to provide?

Accepted Answer

Answer reason: Behavior management for adolescents relies on consistent, predictable limits that caregivers can realistically carry out every time. If parents set consequences they cannot enforce, the limit-setting loses credibility and can unintentionally reinforce substance-related behaviors through inconsistency. Enforceable consequences also reduce power struggles and help maintain a calm, structured environment that supports safety and accountability. Being verbally forceful escalates conflict and can increase oppositional behavior rather than promote change. Saying consequences are seldom needed is inconsistent with effective limit-setting for high-risk behaviors like inhalant abuse.

Question 37

Which is a behavioral intervention that the nurse can use to assist the client who wishes to quit smoking?

Accepted Answer

Answer reason: Behavioral interventions for smoking cessation focus on changing habits and coping responses to cravings through skills training, planning, and support. Practical counseling targets triggers, teaches problem-solving and relapse-prevention strategies, and helps the client create a concrete quit plan—core components of evidence-based cessation counseling. Spirometry and lung examination are assessment activities and do not directly modify smoking behavior. Nicotine patches are pharmacologic therapy, not a behavioral intervention, even though the nurse may provide education about their use.

Question 38

A client with a phobic condition is being treated with behavior modification therapy. Which intervention best addresses this technique?

Accepted Answer

Answer reason: Behavior modification for phobias primarily uses exposure-based strategies to reduce anxiety through habituation and extinction. Systematic, graded, repeated exposure allows the client to experience the feared stimulus while learning that catastrophic outcomes do not occur, gradually decreasing the conditioned fear response. “Face it head-on” implies flooding, which can be poorly tolerated and may increase distress and refusal rather than promoting adherence. Insight-oriented discussion about causes does not directly target the conditioned avoidance behavior that maintains phobias, and ECT is not an indicated treatment for specific phobias.

Question 39

A nurse explains the unit's rules to a client with bulimia nervosa. Which action by the client indicates that learning has occurred?

Accepted Answer

Answer reason: Bulimia treatment commonly includes behavioral limits to reduce opportunities for post-meal purging, such as supervised bathroom use and restricted access immediately after eating. Requesting accompaniment after lunch shows the client understands the rule’s purpose and is participating in a safety-focused plan to prevent compensatory behaviors. Writing down foods may reflect monitoring but does not specifically demonstrate understanding of unit rules aimed at interrupting purging. Discussing problems before meals can be therapeutic, but it is not as directly tied to a standard unit rule designed to prevent vomiting after meals.

Question 40

The cognitively impaired nursing home resident is beginning to show physical signs of agitation. Which activity would be most therapeutic to de-escalate the client's agitation?

Accepted Answer

Answer reason: Gentle physical activity and a change of environment can discharge excess energy, lower anxiety, and provide structured redirection without demanding complex cognitive processing. Having staff accompany the client maintains observation and support, decreasing risk for escalation or injury. Group bingo can be overstimulating and frustrating, and being alone in the room can increase fear or unsafe behavior; passive TV is less reliably calming and may add sensory stimulation.

Question 41

Which statement indicates to the nurse that a female client with bulimia nervosa is making progress in interrupting the binge-purge cycle?

Accepted Answer

Answer reason:  Progress in bulimia is shown by replacing the maladaptive purge response with an adaptive coping strategy when emotional triggers occur. Reaching out for social support during distress helps interrupt the urge–behavior chain that often precedes bingeing and purging. This reflects improved insight and use of healthier coping skills, which is a key treatment goal. By contrast, statements that plan for purging or express hopelessness suggest ongoing reinforcement of the cycle rather than interruption.

Question 42

Which nursing intervention is the most appropriate for a client who had pseudoseizures and is diagnosed with conversion disorder?

Accepted Answer

Answer reason: Conversion disorder symptoms are not intentionally produced, and reinforcement of the sick role can perpetuate episodes. The priority nursing approach is to maintain safety, provide matter-of-fact care, and minimize secondary gain by limiting extra attention to the symptom while supporting normal functioning. Encouraging independence helps shift coping toward adaptive behaviors and reduces reliance on symptoms to meet needs. Confronting the client as if the symptoms are “imaginary” is nontherapeutic and can increase anxiety and defensiveness, worsening symptom expression.

Question 43

A 50-year-old schizophrenic client becomes agitated and confronts the nurse with clenched fists. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: The priority is de-escalation and maintaining safety using the least restrictive, therapeutic approach. A calm tone, nonthreatening stance, and offering a PRN anxiolytic/antipsychotic can reduce agitation and help prevent escalation to violence. Options that involve touching or physically leading the client increase the risk of provoking an assault when the client is already posturing. Seclusion/security is reserved for imminent danger or when less restrictive measures fail, not as the first response when verbal de-escalation is still feasible.

Question 44

What is the best nursing intervention to help a client with conversion disorder blindness to eat?

Accepted Answer

Answer reason: Conversion disorder symptoms are not intentionally produced, and care focuses on promoting function while avoiding reinforcement of the symptom. Providing simple orientation to the environment supports safety and enables the client to attempt normal activity without the nurse “taking over” the task. Having others feed the client increases dependency and can unintentionally validate the disability, making recovery less likely. Directing the client to independently locate items without first orienting the tray is less supportive and may increase anxiety or frustration, which can worsen symptom persistence.

Question 45

A client is admitted to a mental health unit. While assessing the client, the nurse finds the client exhibiting signs of hyperexcitability, increasing agitation, and distractibility. Based on the assessment, which nursing intervention has priority?

Accepted Answer

Answer reason: The priority for escalating agitation with distractibility is to reduce environmental stimuli to prevent further escalation and promote safety. A quiet, low-stimulation setting helps the client regain self-control and decreases triggers from noise, interpersonal demands, and activity. Group activity and planned activities typically increase stimulation and can worsen agitation when the client is hyperexcitable. Being firm and setting rules may be appropriate later, but immediate de-escalation and stimulus reduction come first to lower risk of behavioral escalation.

Question 46

A client with a history of bipolar disorder rushes into the mental health clinic waiting room scantily dressed and makes loud, obscene remarks to other clients. Which intervention by the nurse is most appropriate?

Accepted Answer

Answer reason: Manic/hypomanic behavior can include disinhibition, poor judgment, and sexually inappropriate or intrusive actions; the priority is preserving safety and dignity while setting clear, nonpunitive limits. Moving the client to a private area immediately reduces stimulation and protects other clients from distress or escalation. A calm, respectful approach with concrete assistance (providing a gown) addresses the immediate problem without power struggles that can worsen agitation. Options that scold, confront, or focus on others ignoring the behavior fail to contain the environment and are less therapeutic for de-escalation.

Question 47

The client with paranoid schizophrenia is being discharged. The family member asks, “What should I do if the voices come back again?” Which nurse response is most appropriate?

Accepted Answer

Answer reason:  Auditory hallucinations are managed first with immediate, practical coping strategies that reduce distress and support safety. Staying with the client provides reassurance and monitoring, while distraction/grounding techniques can help shift attention away from the hallucinations and improve reality-based coping. The other responses focus on follow-up or contact numbers, which are helpful resources but do not directly answer what to do in the moment when symptoms recur. This option best reflects a therapeutic, actionable relapse-management plan for hallucinations after discharge.

Question 48

The mental health assistant is assigned to work with the client who has delusions. Which action requires the most immediate attention by the nurse?

Accepted Answer

Answer reason:  Offering to eat the food to “prove” it is safe reinforces the delusional framework and can escalate paranoia by validating that poisoning is a realistic concern requiring a test. It also creates a power struggle and may set up future nonadherence if the client continues to refuse food, because the staff member has already “joined” the delusion rather than responding therapeutically. Appropriate staff responses focus on presenting reality, acknowledging feelings, and encouraging intake without colluding with the delusion. While arguing about the delusion is also nontherapeutic, it is generally less risky than actively validating and acting within the delusional system.

Question 49

The client has developed paranoia as a result of regular methamphetamine use. The nurse uses cognitive reappraisal to confront the client’s persecutory thoughts. Which question should the nurse ask the client?

Accepted Answer

Answer reason:  Cognitive reappraisal aims to help the client reframe an automatic thought by generating alternative, more balanced interpretations. This open-ended prompt directly supports reframing without validating the persecutory belief or escalating defensiveness. In contrast, asking for reasons others would harm them can reinforce the delusion by implying there is a rational basis for persecution. The other options either introduce blame/shame or assume the persecutory premise is true, which is not therapeutic when addressing paranoia related to substance use.

Question 50

When a nurse enters the room to give an antibiotic elixir to a 3-year-old child, the child says the medication is "yucky" and refuses to take it. Which response by the nurse is best?

Accepted Answer

Answer reason:  Toddlers respond best to simple choices that promote autonomy while still accomplishing the needed treatment. Offering two acceptable options uses a developmentally appropriate behavioral strategy that increases cooperation without threats or power struggles. Threatening to “tell your mother” relies on fear and can damage trust, while invoking authority (“doctor says”) is not meaningful to a 3-year-old. A brief explanation about getting better is honest but often insufficient alone to overcome taste aversion at this age compared with structured choice.

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