Question 1

A 38-year-old female client was returning home from the store late in the evening and was sexually assaulted. She is brought to the emergency department and is crying. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Staying with the client provides therapeutic presence, helps reduce intense anxiety, and supports coping while urgent medical/forensic care is arranged. Reporting to police and contacting family may be appropriate later, but they require the client’s consent and can increase distress if done prematurely. Suggesting self-defense classes is inappropriate in the acute phase and may be perceived as blaming rather than supporting recovery.

Question 2

A 14-year-old female client admits to having transsexual feelings and states, “I would rather die than live in this body.” What is the most appropriate initial intervention by the nurse?

Accepted Answer

Answer reason: Suicidal statements require immediate safety assessment before further exploration of feelings. This client’s wording indicates possible suicidal ideation, so the nurse should directly assess for intent/plan to determine imminent risk and the need for urgent protective interventions. Directly asking about suicide does not increase risk and is a critical first step in crisis intervention. Options that normalize, invalidate, or disclose to parents without first determining immediate danger fail to prioritize safety and therapeutic crisis management.

Question 3

The home health nurse is visiting a 72-year-old client with severe osteoarthritis. During the visit, the client tells the nurse that his wife died a year ago. Which statement by the client requires further intervention?

Accepted Answer

Answer reason:  Statements reflecting hopelessness after a loss can indicate suicidal ideation and require immediate assessment for safety. This comment suggests passive suicidality and warrants further intervention such as direct questioning about thoughts, plan, intent, and access to means, plus urgent referral if risk is present. In contrast, limited family availability and dissatisfaction with pain are common stressors but do not inherently imply self-harm risk. Mild memory concerns after losing a spouse who provided cues may be normal adjustment or aging and should be assessed, but it is less emergent than potential self-harm.

Question 4

The nurse overheats the client talking with her husband about her new diagnosis of stage 1 breast cancer. Which statement by the client indicates that she does not fully understood the diagnosis?

Accepted Answer

Answer reason:  Stage I breast cancer is typically localized with a generally favorable prognosis when treated, so catastrophic statements suggest the client is misinterpreting the diagnosis as imminently terminal. This reflects maladaptive crisis thinking (hopelessness/overestimation of immediate mortality) rather than accurate understanding of early-stage disease. By contrast, discussing possible chemotherapy or radiation can be consistent with stage I management depending on tumor biology and surgical approach. The statement about being early and contained aligns most closely with what stage I commonly indicates.

Question 5

The nurse observes that the client with a history of violent command hallucinations mumbles erratically while making threatening gestures directed toward a particular staff member. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: Close observation allows the nurse to identify progression from agitation to loss of control and to mobilize support (e.g., additional staff, environmental control) before harm occurs. Seclusion and restraints are last-resort interventions used only when less restrictive measures fail and there is immediate danger, not as an initial response. Asking for explanations or giving conditional threats can increase stimulation and confrontation, potentially worsening agitation and risk.

Question 6

The client is being discharged after hospitalization for a suicide attempt. Which question asked by the nurse assesses the learned prevention and future coping strategies of the client?

Accepted Answer

Answer reason: " Effective discharge planning after a suicide attempt focuses on relapse prevention by confirming the client can identify and use concrete coping strategies during future crises. This question directly assesses whether the client has learned skills (e.g., problem-solving, reaching out, using a safety plan) and can apply them when stressors recur. By contrast, asking about method or “why” primarily explores past behavior and can increase defensiveness without evaluating readiness for safe coping. While knowing a hotline number is useful, it checks a single resource rather than the broader set of coping and prevention strategies needed to reduce recurrence risk.

Question 7

The client presents to the ED reporting that he was sexually assaulted by several men he met at a local bar. Which action should the nurse plan to include when preparing to assess the client?

Accepted Answer

Answer reason: Sexual-assault assessment is guided by trauma-informed, nonjudgmental interviewing that prioritizes safety, dignity, and evidence preservation regardless of the client’s sex or the assailants’ identities. Using the same structured approach helps avoid bias, reduces re-traumatization, and ensures consistent medical/forensic care and appropriate referrals. Questions implying blame (e.g., focusing on resistance) are inappropriate and can hinder disclosure and trust. Assigning care based on nurse gender is not required; instead, the nurse should offer privacy, explain options, and support the client’s choices.

Question 8

The client diagnosed with schizophrenia is refusing to take a prescribed psychotropic medication. The nurse attempts to persuade the client to comply with the HCP’s orders. Under which circumstance could the client be forced to take medication?

Accepted Answer

Answer reason: A direct, credible threat to kill staff indicates imminent danger and can justify emergency measures, including involuntary administration of medication per facility policy and legal authority. Grandiose or bizarre delusions alone do not meet the threshold for forced treatment if the client is not imminently dangerous. A past suicide attempt without current imminent intent/plan typically prompts assessment and safety precautions, not automatic forced medication.

Question 9

The school nurse is planning an intervention program for children who lost their homes due to a tornado and are now residing in temporary housing. Which group should be the nurse’s initial focus?

Accepted Answer

Answer reason: Younger children have less-developed coping skills and greater dependence on stable routines and caregivers, increasing risk for anxiety, regression, and behavioral problems after displacement. Lower socioeconomic status typically means fewer buffers (transportation, access to services, stable childcare, financial reserves), making it harder to meet basic needs in temporary housing. Boys are often more likely to externalize stress (aggression, acting out), which can disrupt school functioning and safety and signal need for early intervention. Focusing first on the highest-risk subgroup helps allocate limited post-disaster supports where they are most likely to prevent harm.

Question 10

The nurse has compiled an admission assessment on an ex-military serviceman who has served two tours in Iraq and is now retired from military service. The assessment data include the following: The client is upset, continually fidgeting, makes no eye contact, and responds to questions with “yes” and “no” answers. What is the priority nursing intervention?

Accepted Answer

Answer reason: Acute behavioral cues such as agitation, poor eye contact, minimal verbal engagement, and marked distress require immediate safety screening before exploratory psychosocial discussion. Directly assessing suicidal ideation is a priority because it identifies imminent risk and guides urgent protective actions if needed (e.g., close observation, mental health consult). The other options are therapeutic but nonurgent and should be addressed only after life-threatening risk is ruled out. A common error is avoiding direct questioning, but asking clearly does not increase risk and is essential to crisis assessment.

Question 11

A 23-year-old female client is seen in the emergency department for rape. The woman is very calm and appears emotionally unaffected by the event. Which assessment of the client’s behavior is appropriate?

Accepted Answer

Answer reason: After sexual assault, emotional responses vary widely and may include numbness, dissociation, denial, or shock, which can present as an unusually calm affect. A trauma-informed assessment avoids judgment and recognizes that outward behavior is not a reliable indicator of internal distress or the event’s validity. This interpretation supports appropriate crisis intervention and helps the nurse maintain a supportive, nonblaming stance. The other options reflect victim-blaming or unsupported assumptions that can retraumatize the client and interfere with care and reporting.

Question 12

The client has been violent toward other clients on a mental health unit, and interventions have failed. During the application of restraints, which action by the team leader will gain the greatest cooperation from the client?

Accepted Answer

Answer reason: A matter-of-fact explanation of the reason and the steps sets firm limits, conveys control and predictability, and can lower anxiety, which improves cooperation. Apologizing can imply the intervention is optional or unfair and may invite argument, while conditional bargaining ("behaving"/"control the anger") is vague and can escalate mistrust or manipulation. Clear communication paired with consistent limit-setting is the most therapeutic way to implement restraints safely.

Question 13

The client has been placed in restraints for violent behavior. Which statement best indicates the nurse’s understanding of the risk for client injury while being restrained?

Accepted Answer

Answer reason:  Restraints create a high risk of injury and medical compromise (airway obstruction, aspiration, impaired circulation/nerve injury, rhabdomyolysis, and sudden deterioration), so the safety priority is continuous observation with rapid intervention if status changes. This statement shows the nurse understands that monitoring cannot be interrupted and must be handed off to maintain constant supervision. It also reflects awareness that restrained, violent clients can quickly escalate or attempt to self-harm despite being secured, requiring immediate response. By contrast, checking equipment function is important but does not address the ongoing physiologic and safety risks that require uninterrupted monitoring.

Question 14

The nurse educator is orienting new nursing staff to the behavioral care unit when one nurse asks, “How will I know which clients are potentially violent?” Which response by the nurse educator is best?

Accepted Answer

Answer reason:  Past violent behavior is one of the strongest predictors of future violence risk and is a concrete, actionable assessment step for staff safety planning. Reviewing documentation for prior aggression, triggers, and effective de-escalation strategies allows the nurse to implement precautions early (e.g., observation level, environment control, team approach). Behavioral “clues” can be subtle or late signs and are not as reliable as a documented history when proactively identifying risk. Relying on clients to verbalize anger is unsafe because escalation may occur without warning or disclosure.

Question 15

The new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement, made by the new nurse, reflects an immediate need for follow-up by the mentor?

Accepted Answer

Answer reason:  With escalating aggression in a cognitively impaired client, safety and early de-escalation strategies that reduce stimulation and maintain distance are prioritized because reasoning and negotiation may be ineffective and can further escalate the situation. Attempting to “talk down” an actively escalating, violence-prone client suggests reliance on verbal negotiation rather than promptly implementing a structured escalation protocol (calm limit-setting, calling for assistance, environmental control, and preparing for emergency measures per policy). This statement signals potential underrecognition of imminent risk and delayed activation of help, which places staff and other clients at higher danger. By contrast, focusing on unit safety, reducing triggers (e.g., turning off TV), and using consistent staffing are appropriate preventive strategies for violence risk.

Question 16

The nurse is developing the plan of care for the client diagnosed with schizophrenia who is having an alcohol-induced crisis. Which specific client outcome best reflects the primary goal of crisis intervention for this client?

Accepted Answer

Answer reason: Crisis intervention prioritizes immediate stabilization and restoring the client’s precrisis level of functioning by improving problem-solving and coping in the here-and-now. Identifying specific coping strategies demonstrates the client can manage acute stressors and reduce the likelihood of escalation or relapse after discharge. Detoxification timelines and return-to-work goals are longer-term rehabilitation outcomes and are not the primary focus during the acute crisis phase. Medication self-administration is important for ongoing management of schizophrenia, but it does not directly capture the central aim of crisis care: short-term coping and safety-oriented stabilization.

Question 17

The 28-year-old is being seen in the ED with injuries after being assaulted by her live-in boyfriend. The client acknowledges that this is not the first time that she has been assaulted and that she is afraid. Which client action indicates that an out- come for the client has been achieved?

Accepted Answer

Answer reason: Agreeing to a shelter plan indicates engagement with a safer environment and access to advocacy, legal resources, and ongoing support. Returning to the partner reflects continued exposure to harm and does not meet safety goals. Staying overnight in the hospital may provide temporary protection but does not establish a longer-term safety plan, and Adult Protective Services generally targets vulnerable adults (e.g., elderly/disabled) rather than an otherwise competent 28-year-old.

Question 18

The indigent client with both emotional and physical diagnoses has just attended a discharge planning session with the nurse. Which client behavior shows the greatest commitment to the client’s self-management?

Accepted Answer

Answer reason: Actively identifying and contacting community supports shows follow-through, problem-solving, and engagement with a long-term support system—critical for an indigent client managing both mental and physical conditions. Knowing medications or verbally promising follow-up reflects understanding or intention, but does not yet show action to overcome real-world barriers. Seeking temporary housing help is appropriate, but it represents a specific immediate need rather than comprehensive engagement with ongoing self-management supports.

Question 19

When debriefing the unit’s staff after the client’s catastrophic reaction, the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?

Accepted Answer

Answer reason: In crisis and potential violence situations, staff affect and behavior can either de-escalate or escalate a client’s arousal level. Visible anxiety, rapid movements, loud voices, or a tense posture can be perceived as threat, increasing the client’s fear and loss of control and thereby intensifying aggression. A calm, controlled approach supports therapeutic communication, maintains a nonthreatening milieu, and helps the client regain behavioral control. While poor staff performance (option B) may be true, the key safety mechanism being tested is emotional contagion and escalation dynamics during a behavioral emergency.

Question 20

The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma- What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?

Accepted Answer

Answer reason: Cognitive impairment after head trauma commonly reduces the ability to accurately interpret environmental input and to modulate arousal. When stimulation is misread as threatening or becomes overwhelming, the client can rapidly escalate into fight-or-flight behavior with poor impulse control, increasing risk of sudden severe violence. Nursing prevention in these situations centers on decreasing stimuli, using simple cues, and maintaining a calm, structured milieu to avoid triggering overload. Limited information processing can contribute to frustration, but sensory misinterpretation and low tolerance are more directly linked to explosive, catastrophic reactions. The staff-focused options describe unit dynamics rather than the client’s primary neurocognitive vulnerability driving escalation.

Question 21

The nurse is evaluating the client who threatens suicide. Which nursing intervention is most effective in establishing a safe environment for the client?

Accepted Answer

Answer reason: Imminent suicide risk requires the highest level of safety through continuous, direct monitoring to prevent impulsive self-harm and allow immediate intervention. One-to-one observation ensures rapid response to changes in behavior, access to means, or escalation of intent, which environmental changes alone cannot reliably prevent. Removing potential implements is essential but is not sufficient because many hazards can be missed and clients may use unexpected methods. Seclusion or group activities do not provide the constant, individualized supervision required when a client is actively threatening suicide.

Question 22

The client is displaying behaviors consistent with stage 2 Alzheimer’s disease. The client can no longer recognize family members and requires assistance with personal hygiene and dressing. The client is frequently incontinent of both urine and feces and displays violent outbursts during these times. Which nursing problem should be the nurse’s priority?

Accepted Answer

Answer reason: The stem indicates violent outbursts occurring with incontinence episodes, which signals a need for immediate crisis management and de-escalation to prevent injury. While incontinence, self-care deficits, and impaired memory are expected problems in Alzheimer’s disease, they are not as time-critical as uncontrolled violent behavior. Addressing triggers, maintaining a safe environment, and implementing behavioral strategies come before longer-term hygiene/toileting plans.

Question 23

A 20-year-old female client is in the emergency department after being sexually assaulted by a stranger. Which nursing intervention has the highest priority?

Accepted Answer

Answer reason: Identifying supportive family or friends promotes immediate psychological containment, reduces isolation, and helps the client tolerate acute distress while ED care and follow-up planning proceed. Options that explore causation or childhood history are inappropriate in the acute phase and can be victim-blaming or overwhelming. Scheduling a crisis-center appointment in 6 weeks delays needed support and does not address the client’s urgent psychosocial needs now.

Question 24

The client’s spouse is allowed to be present during resuscitation efforts. Which statement made by the nurse is most appropriate?

Accepted Answer

Answer reason:  Family presence during resuscitation should be supported with structure to maintain patient safety and team performance while addressing acute distress. Assigning a staff member to stay with the spouse provides coaching, emotional support, and ensures the spouse does not inadvertently disrupt care. This response is therapeutic, sets clear expectations, and preserves a safe environment during an emergency. The other options are either unrealistic during active CPR, authoritarian and non-therapeutic, or incorrectly suggest the spouse directs termination of resuscitation rather than the clinical team following orders and applicable policies/advance directives.

Question 25

The client is visibly upset, pounding on the desk at the nurses’ station and shouting,” You’re the nurse, so you have to fix this now.” What should be the nurse’s primary rationale for recognizing that the client is a danger to staff and other clients?

Accepted Answer

Answer reason: Imminent risk assessment in agitation/violence is driven by direct threats plus escalating, aggressive behavior (shouting, pounding), which are strong predictors of potential assault. A demand framed as coercive and threatening indicates loss of behavioral control and immediate danger to staff and nearby clients, prompting rapid safety measures and de-escalation. The other options describe poor insight or maladaptive coping styles but do not, by themselves, establish immediate risk of harm. In crisis situations, explicit threatening language combined with violent posturing is the most urgent cue for activating a safety-focused response.

Question 26

The client recently prescribed haloperidol is experiencing severe muscle pain. Assessment findings include a heart rate of 104 bpm, BP of 172/92 mm Hg, and an oral temperature of 101.2°F (384° C). What should the nurse do next?

Accepted Answer

Answer reason: These findings after starting haloperidol raise concern for neuroleptic malignant syndrome, a life-threatening reaction characterized by severe muscle rigidity/pain, hyperthermia, and autonomic instability (tachycardia, hypertension). The priority nursing action is rapid escalation so the prescriber can stop the antipsychotic and initiate urgent treatment (supportive care, cooling, IV fluids, and specific therapy as indicated). Attributing symptoms to infection or cardiovascular history delays time-sensitive management of a medication emergency. Reassuring the client that the symptoms are unrelated to the medication is unsafe because it minimizes a potentially fatal adverse effect.

Question 27

The client has a history of hallucinations and is at risk to harm self or others. In preparing the client for discharge, the nurse provides instructions regarding interventions directed toward managing hallucinations and anxiety. Which statement indicates that the client has an appropriate understanding of the instructions?

Accepted Answer

Answer reason: " A key discharge safety principle for clients with hallucinations and potential for harm is to use a preplanned, immediate coping/safety step and promptly engage professional support when symptoms escalate. Contacting the therapist during hallucinations supports early intervention, reinforcement of coping strategies, and risk assessment to prevent progression to unsafe behavior. The medication statement is incorrect because anxiety can occur as a symptom of illness or as an adverse effect of some psychotropic agents, so dismissing it is unsafe. Support groups and healthy sleep/nutrition can be helpful long-term, but they are not the most direct, action-oriented response for acute symptom recurrence at home.

Question 28

The client is being treated after surviving a major hurricane that took the lives of many neighbors. Which statement by the client provides the nurse with the best evidence that therapy has been successful?

Accepted Answer

Answer reason:  Successful crisis therapy is reflected by adaptive coping, restored functioning, and integration of the traumatic event without avoidance or distorted beliefs. This statement demonstrates acceptance of what occurred while expressing future orientation and readiness to re-engage with life, which are core outcomes of effective crisis intervention. In contrast, minimizing or globalizing statements can signal maladaptive coping or unresolved trauma and increased risk for anxiety/depression. Positive comments about therapy or self-insight alone do not confirm functional recovery as clearly as an expressed ability to resume life roles despite the loss.

Question 29

A client hears voices telling him that he is a terrible person who would be better off dead. Which of the following would be a priority nursing diagnosis?

Accepted Answer

Answer reason: The priority nursing diagnosis focuses on preventing self-harm because the client may act on the voices, especially if they include self-destructive commands or intense hopelessness. Nursing care should prioritize suicide risk assessment, close observation, and environmental safety measures before addressing communication or social functioning. While disturbed sensory perception is present, it is not as time-critical as the potential for imminent self-directed violence.

Question 30

The nurse is caring for a client experiencing an anxiety attack. Appropriate nursing interventions include?

Accepted Answer

Answer reason: During acute anxiety/panic, the priority is to reduce fear and support physiologic and cognitive control using a calm, structured, reassuring presence. Remaining with the client promotes safety and conveys containment, while brief, simple statements match the client’s limited ability to process information during heightened anxiety. Leaving the client alone can worsen panic, increase risk of unsafe behavior, and decreases the sense of support. Extra stimulation (e.g., stereo music) or environmental changes that may feel activating can aggravate symptoms rather than de-escalate them.

Question 31

During a group therapy session, a patient with a panic disorder suddenly complains of shortness of breath and begins to hyperventilate. What is the best way for the nurse to respond?

Accepted Answer

Answer reason: A panic attack with hyperventilation is an acute crisis where the priority is immediate symptom reduction and restoring effective ventilation. Reducing environmental stimuli and coaching slow, controlled breathing helps counter respiratory alkalosis and decreases the physiologic escalation of anxiety. Group processing and feedback is inappropriate during an acute episode and can increase embarrassment and anxiety. Benzodiazepines may be used in some cases but are not the first-line immediate nursing response in the middle of a group session, especially without an order and assessment. Distraction alone is less effective than directly addressing the hyperventilation and providing calm, structured support.

Question 32

A client with a history of bipolar disorder admits to feelings of hopelessness and recent hardships on a social, financial, and mental scale. To further assess the client, the priority question would be which of the following?

Accepted Answer

Answer reason:  Client safety is the immediate priority when hopelessness is disclosed because it can signal imminent suicide risk. Directly assessing for self-harm ideation identifies whether emergency interventions (e.g., constant observation, removal of hazards, urgent psychiatric evaluation) are needed. This question is specific, time-sensitive, and guides the next safest nursing actions. Other options gather useful psychosocial history, but they do not address the highest-risk, potentially life-threatening concern first.

Question 33

A patient admitted for an intentional drug overdose is on day three of an inpatient stay. During the morning assessment, the patient is in a positive mood and states how happy she feels. This is a change from her flat affect since admission. She asks for paper and pen “to make some lists. I want to clean out my house and give some of my stuff to friends. Oh, that will feel so good!” What should the nurse do?

Accepted Answer

Answer reason: Giving away possessions and making lists to “clean out” are classic preparatory behaviors that warrant immediate, direct suicide-risk assessment. The safest nursing action is to explore current suicidal ideation, intent, plan, means, and protective factors and promptly escalate to the treatment team per facility protocol. Simply granting supplies or redirecting/denying the request misses the safety priority and can delay recognition of imminent risk.

Question 34

A nurse is assessing a patient who has a history of major depressive disorder and recently expressed feelings of hopelessness. Which of the following statements by the patient would indicate the highest risk for suicide?

Accepted Answer

Answer reason: Preparatory behaviors and concrete actions consistent with making arrangements are strong indicators of imminent suicide risk. Giving away valued possessions suggests the patient is organizing for death and has moved beyond passive thoughts into planning-related behavior, which requires immediate safety interventions. In contrast, hopelessness, feeling like a burden, or passive death wishes are serious but generally indicate lower immediacy unless paired with a plan, intent, or means. This statement should prompt urgent suicide risk assessment, removal of means, and close observation per facility protocol.

Question 35

A psychiatric home health nurse is planning client visits for the day. Which of the following patients should the nurse see first?

Accepted Answer

Answer reason: Command hallucinations directing harm toward others indicate an immediate risk of violence and require urgent intervention. This situation poses a direct safety threat and takes priority over non-acute behavioral issues, eating disorders, or depression without expressed intent to harm.

Question 36

A patient with major depressive disorder should be evaluated for which possible behavior?

Accepted Answer

Answer reason: Depressive symptoms such as hopelessness, anhedonia, and impaired problem-solving increase the likelihood of suicidal thoughts, plans, and attempts. Direct assessment allows immediate risk stratification and initiation of protective interventions (e.g., safety planning, observation level, removal of lethal means). By contrast, flight of ideas and risky sexual behavior are more typical of manic/hypomanic states rather than unipolar depression.

Question 37

A nurse is caring for a patient following the sudden death of a spouse. The patient feels paralyzed and cannot cope with work or family responsibilities. Which type of crisis is the patient experiencing?

Accepted Answer

Answer reason: The sudden death of a spouse is an acute life event that can abruptly disrupt role functioning and perceived ability to manage daily responsibilities, matching this definition. Adventitious crises are related to rare, extraordinary events (e.g., natural disasters, terrorism), which is not the case here. Developmental/maturational crises are tied to normal life transitions and predictable growth stages rather than an abrupt, unforeseen loss.

Question 38

A client states his goal for hospitalization is “to get a handle on my nervousness.” He was admitted after expressing suicidal intent but seeking help instead. The nurse recognizes that the client has conceptualized his problem. What is the next priority goal in the plan of care?

Accepted Answer

Answer reason: After a client recognizes and defines the problem, the next step in crisis intervention is to explore and develop alternative solutions. This helps the client identify safer coping strategies and reduces the risk of harmful actions. Meaning-making and deeper exploration occur later in the process.

Question 39

The nurse on an inpatient mental health unit is admitting a patient who reports they just lost their job and are feeling hopeless. What should the nurse assess first?

Accepted Answer

Answer reason: The first assessment should determine presence of suicidal ideation, intent, plan, access to means, and prior attempts to guide urgent interventions (e.g., observation level, removal of hazards, provider notification). Information about coping skills and support systems is important, but it does not address an imminent threat to life. Psychiatric history helps with diagnosis and long-term planning, but it is not the first priority when acute risk may be present.

Question 40

A 25-year-old female client with a history of borderline personality disorder is admitted to the psychiatric unit after a suicide gesture involving ingestion of 2 ounces of shampoo. The client reports feeling “empty” and states, “No one cares about me.” Vital signs are stable, and the client is medically cleared. Drag and drop the nursing interventions in order of priority?

Accepted Answer

Answer reason: This assessment guides the level of observation, environmental safety measures, and need for urgent provider notification. Supportive presence and de-escalation are appropriate next steps once imminent risk has been evaluated. Medication and longer-term teaching are not first because they do not establish whether there is an active, time-sensitive risk of self-harm requiring immediate containment.

Question 41

The nurse is assessing four psychiatric clients during morning rounds. Which client requires immediate intervention?

Accepted Answer

Answer reason: A stated suicide plan with preparatory intent signals imminent risk and demands immediate safety actions. Requesting “a few things from home” suggests access to means and movement toward carrying out the plan, requiring constant observation, removal of potential tools, and rapid provider notification per facility protocol. In contrast, depressed appetite and a non-command hallucination warrant assessment and support but are not as immediately life-threatening. Acute mania needs prompt management to reduce exhaustion and risky behavior, but it is typically secondary to an explicit, imminent self-harm plan in priority.

Question 42

A client is experiencing an anxiety attack. Which is the most appropriate nursing intervention for this specific client?

Accepted Answer

Answer reason: Remaining with the client provides immediate safety, conveys calm control, and allows rapid assessment of breathing, behavior, and need for further intervention. Using brief, simple statements minimizes stimulation and supports grounding when concentration is impaired. In contrast, leaving the client alone or adding external stimuli can worsen agitation and delay recognition of deterioration.

Question 43

The nurse is assessing a client with depression. Which of the following statements by the client would be a priority to follow up?

Accepted Answer

Answer reason: " Priority assessment in depression is immediate safety, including screening for suicidal ideation and preparatory behaviors. Settling financial affairs can represent putting personal matters “in order,” a potential warning sign of impending self-harm that warrants direct, urgent follow-up questioning about thoughts, plan, means, and intent. In contrast, loneliness after a breakup and family relationship strain suggest psychosocial stressors but are not as time-sensitive as a possible pre-suicide behavior. Weight-loss efforts are nonspecific and only become urgent if tied to severe self-neglect or medical instability.

Question 44

The nurse is caring for a client who was sexually assaulted 4 hours ago. The client states, "If I had fought harder and resisted the attack this would not have happened." Which of the following responses would be appropriate for the nurse to make initially?

Accepted Answer

Answer reason: " The priority after a recent sexual assault is crisis intervention using therapeutic communication that reduces self-blame and supports coping. This response acknowledges the client’s feelings without implying responsibility for the assault and reframes the client’s behavior as a protective survival response. Asking about safety techniques can be perceived as blaming and shifts focus away from the immediate emotional crisis. Collecting detailed information and offering referrals are important, but the initial response should first provide emotional support and validation before moving into assessment and next-step resources.

Question 45

A client who was placed in restraints appears in the hallway an hour later and states, "I'm Houdini... I can get out of anything. There could be trouble now." Which of the following is the best response to this client?

Accepted Answer

Answer reason: " The priority is to assess for imminent risk of harm by using direct, therapeutic, open-ended questioning when a client makes a vague statement implying possible violence. This response invites the client to clarify intent and content (e.g., threats to self/others) so the nurse can determine the level of danger and intervene promptly. It also demonstrates active listening and de-escalation rather than focusing on curiosity about how the restraints were escaped. Silently signaling staff may be appropriate if immediate danger is evident, but first-line care here is to assess the threat while maintaining engagement and safety awareness.

Question 46

A psychiatric nurse who is a member of a mobile crisis team is called to deal with a person who is threatening to jump off a bridge in a suicide attempt. On arrival at the site, the nurse immediately?

Accepted Answer

Answer reason: Approaching with nonjudgmental listening and a therapeutic connection increases cooperation and decreases the likelihood of impulsive action. Physically grabbing the person can startle them, provoke a struggle, and increase the chance of falling. A moralizing statement is nontherapeutic and can increase shame or resistance; involving law enforcement may be necessary for safety but is not the nurse’s immediate therapeutic action on arrival.

Question 47

The nurse is working at a mental health clinic. Which client should the nurse turn her attention to first?

Accepted Answer

Answer reason: Suicidal ideation with an implied wish to die is an immediate safety threat and requires priority assessment and intervention. This statement suggests possible intent or planning and places the client at high risk for self-harm, so the nurse must perform a focused suicide risk assessment, ensure safety, and initiate crisis measures without delay. The other clients demonstrate concerning conditions, but none present an explicit, time-sensitive risk of imminent death at the moment. In triage, potential for self-harm supersedes grooming changes in depression, suspected eating disorder without acute instability described, or non-dangerous compulsive behavior.

Question 48

Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?

Accepted Answer

Answer reason:  Any expression suggesting hopelessness or a desire to not continue living requires immediate safety assessment because it may indicate suicidal ideation. This statement implies potential self-harm risk, so the nurse should promptly perform a suicide risk screen, assess intent/plan/means, ensure close observation, and initiate appropriate mental health resources. The other statements reflect anger, anxiety about adjustment, or apprehension about discharge, which are common grief/adaptation responses after life-altering injury and are not as immediately life-threatening. Immediate follow-up prioritizes protecting the client from imminent harm while supporting coping and adaptation.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Crisis Intervention NCLEX Practice Test

Continue Learning