Question 1

While the nurse is caring for the client with posttraumatic stress disorder (PTSD), the client states, "I don't sleep. Why is that important?" What is the best response by the nurse?

Accepted Answer

Answer reason: " Sleep disturbance is a core feature of PTSD and can worsen hyperarousal, intrusive symptoms, irritability, and daytime functioning. Linking better sleep to global symptom improvement provides accurate psychoeducation and supports motivation for sleep-focused interventions (e.g., sleep hygiene, CBT-I, nightmare treatment). This response is broad, therapeutic, and aligns with the client’s question about why sleep matters, rather than focusing narrowly on only one symptom. A statement emphasizing nightmares alone can be true but is less comprehensive and may not address the overall impact of sleep on PTSD.

Question 2

A client with a diagnosis of posttraumatic stress disorder (PTSD) tells the nurse, "When things get really bad, it sometimes feels like I'm not even in my body, like I'm floating around and watching myself." How should the nurse best interpret this client's statement?

Accepted Answer

Answer reason: PTSD can include dissociative symptoms, especially during periods of intense distress or trauma reminders, as a protective coping response. Hyperarousal is more consistent with autonomic symptoms like tachycardia, sweating, and exaggerated startle rather than feeling unreal or "floating." The statement alone does not establish imminent danger or functional inability requiring constant supervision or inpatient hospitalization; those decisions require evidence of safety risk, psychosis, or severe impairment.

Question 3

A psychiatric-mental health nurse is teaching the family members of a client about strategies for engaging with their family member who has recently been diagnosed with posttraumatic stress disorder (PTSD). The nurse should encourage the client’s family to?

Accepted Answer

Answer reason: PTSD commonly presents with hyperarousal, negative alterations in mood/cognition, and avoidance, which can manifest as irritability, emotional numbing, and social withdrawal. Teaching families to anticipate these symptoms supports realistic expectations, reduces misinterpretation as intentional rudeness, and promotes supportive, nonjudgmental communication. The other options are unsafe or inaccurate: benzodiazepines are not a routine daily “same time each day” strategy due to dependence and symptom-worsening risks in some patients, and fragmented daytime sleep is not a recommended expectation. Forcing social interaction when the client is opposed can escalate anxiety and avoidance, so gradual, patient-centered engagement is preferred.

Question 4

A school health nurse is seeing a child. The teacher has described this child as being self-isolating and nonparticipatory in class while their grades remain acceptable. What would the nurse suspect is occurring with this child?

Accepted Answer

Answer reason: This pattern is more consistent with an anxiety disorder than with cognitive or motivational decline, since grades are acceptable despite reduced classroom engagement. Bullying can also cause avoidance, but the stem emphasizes a persistent nonparticipatory pattern without other cues (e.g., fear of specific peers, injuries, or sudden grade decline) that would more strongly point to victimization. Manipulative behavior is less likely because it implies intentional goal-directed behavior, whereas social anxiety is driven by distress and avoidance. Substance use in school-aged children more commonly correlates with functional deterioration and behavioral changes rather than isolated class nonparticipation with preserved grades.

Question 5

A client reports experiencing a panic attack when driving through a tunnel since having their car breakdown in a tunnel during rush hour several months ago. In which way would the nurse interpret the client’s panic attacks?

Accepted Answer

Answer reason: The tunnel has become a conditioned cue linked to the original breakdown experience, so re-exposure triggers anticipatory anxiety and panic. This interpretation best explains why symptoms occur in a specific context without requiring a primary structural brain abnormality. GABA receptor “overstimulation” would be expected to reduce anxiety rather than provoke panic, making it an unlikely mechanism for the described pattern.

Question 6

A client suspects they may be experiencing posttraumatic stress disorder (PTSD) several months after being assaulted in a parking lot. Which is an appropriate nursing action to address this suspicion?

Accepted Answer

Answer reason: Standard nursing practice is to begin with appropriate screening/assessment tools when PTSD is suspected, especially when symptoms persist months after a traumatic event. The LEC-5 is a validated instrument used to document exposure to potentially traumatic events and supports further evaluation of PTSD symptoms when paired with additional assessment (e.g., symptom checklists/clinical interview). Telling the client it will “improve over time” is nontherapeutic and risks minimizing symptoms and delaying care. Forcing the client to relive the event in detail can worsen distress and is not an initial nursing action; medication referral may be appropriate later but should follow assessment and is not the first step.

Question 7

A 14-year-old survived a house fire in which a younger sibling died. What assessment finding would support a diagnosis of posttraumatic stress disorder (PTSD)?

Accepted Answer

Answer reason: Survivor guilt that is intense and tied to perceived responsibility for the death reflects this PTSD domain and suggests the trauma is being processed with maladaptive self-blame. In contrast, crying when discussing the tragedy and idealizing the relationship are common grief responses and do not specifically indicate PTSD. Fixation on safety planning may reflect anxiety or adaptive coping unless it is excessive, intrusive, and impairing, which is not established here.

Question 8

What assessment finding would suggest to the nurse that the client with posttraumatic stress disorder (PTSD) is experiencing dissociation?

Accepted Answer

Answer reason: The described blank staring plus inability to account for elapsed time is a classic assessment clue for dissociative episodes (depersonalization/derealization or dissociative amnesia). By contrast, sleep maintenance insomnia is a common PTSD symptom but reflects hyperarousal rather than altered consciousness. Ineffective coping and mood-incongruent statements can occur with trauma-related distress, but they do not specifically indicate a dissociative state with impaired time awareness.

Question 9

The family members of a military veteran are distraught that he has withdrawn from them emotionally after returning home from a tour of duty. What is the nurse's most appropriate action?

Accepted Answer

Answer reason: A focused assessment can identify hallmark clusters (intrusion, avoidance, negative mood/cognition changes, and hyperarousal) and evaluate functional impairment and safety risks (e.g., depression, substance use, suicidal ideation). Education and family meetings may be helpful later, but without confirming the underlying problem they risk minimizing symptoms or escalating distress. Clarifying whether symptoms meet criteria and their severity guides appropriate referral, therapy planning, and family support strategies.

Question 10

A client with posttraumatic stress disorder (PTSD) suffered injuries in a workplace fire several months ago and now admits that the client is reluctant to join family members on a camping trip. The client states, "The last place I want to be is sitting around a bonfire, pretending to have a good time." The nurse should recognize the characteristics of?

Accepted Answer

Answer reason: PTSD commonly involves avoidance of trauma-related cues, along with intrusive symptoms and negative mood/cognition changes. The client refuses a camping trip specifically because a bonfire resembles the workplace fire, indicating deliberate efforts to avoid reminders that trigger distress. This is distinct from dissociative symptoms like depersonalization/derealization, which involve feeling detached from oneself or surroundings rather than actively steering away from a trigger. Emotional numbing reflects diminished responsiveness or interest, but the key feature here is behavioral and cognitive avoidance of a specific trauma reminder.

Question 11

When caring for a client who is experiencing the symptomology of acute stress disorder, the nurse recognizes the importance of minimizing the client's risk for developing which condition?

Accepted Answer

Answer reason: The key clinical concern is progression of persistent trauma-related symptoms beyond 1 month, which meets criteria for PTSD. Nursing care focuses on early identification, trauma-informed support, sleep/restoration, and referral for evidence-based therapy to reduce chronicity. Dissociative amnesia and emotional numbness are potential symptoms within acute stress reactions rather than the primary longer-term disorder to prevent. Paranoia is not the typical sequela targeted in acute stress disorder prevention planning.

Question 12

A mother brings her 3-year-old child in, as she is concerned because the child continuously bangs his head and bites himself. Which of the following mental disorders should the nurse assess the child for?

Accepted Answer

Answer reason: g., head banging, self-biting) are characteristic of stereotypies, particularly when they are persistent and cause impairment or injury. This presentation best fits the diagnostic concept of stereotypic movement disorder rather than a tic disorder, which typically involves sudden, rapid, nonrhythmic movements or vocalizations and is less commonly described as sustained self-injurious behavior. Tourette’s requires multiple motor tics plus at least one vocal tic over time, which is not suggested here. Encopresis is fecal incontinence/soiling and does not explain repetitive self-injury.

Question 13

The nurse is caring for a client with schizophrenia, who is speaking words and phrases that are unrelated to one another. The nurse should document this communication pattern as?

Accepted Answer

Answer reason: This reflects a formal thought disorder in which speech is a jumble of words and phrases with little to no logical connection, making it largely incomprehensible. That pattern is classic for disorganized thinking seen in schizophrenia and is documented as an impairment in thought process and communication. By contrast, pressured speech is rapid and difficult to interrupt but can still be goal-directed, and clang association is driven by rhyming/sound rather than meaning. Neologisms are newly invented words, which is a different specific abnormality than unrelated, incoherent phrasing.

Question 14

While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?

Accepted Answer

Answer reason: This commonly manifests as negative self-concept and dissatisfaction with appearance, making disturbed body image a frequent associated issue for nursing assessment. The other options describe risk behaviors that can occur in some adolescents but are not the most typical or direct association of obesity itself. Nursing care should therefore include screening for self-esteem concerns, depression/anxiety symptoms, and supportive counseling around healthy behaviors.

Question 15

A client is admitted to a psychiatric unit with delusions. What findings can the nurse expect?

Accepted Answer

Answer reason: As a result, the client may distrust staff motives, question care, and refuse or resist therapeutic interactions and interventions. This presentation aligns most directly with suspiciousness and difficulty engaging in treatment. Flight of ideas and hyperactivity is more characteristic of manic states, while anorexia/hopelessness and panic with somatic complaints better fit depressive and anxiety-related disorders.

Question 16

Which statement made by a client indicates to the nurse that he may have a thought disorder?

Accepted Answer

Answer reason: “I can’t find my ‘mesmer’ shoes. Have you seen them?” Thought disorders are suggested by disrupted, illogical, or idiosyncratic thinking patterns that show up in speech, including neologisms (made-up words) or unusual word usage. Using a nonstandard term like “mesmer” in a way that appears meaningful only to the client is consistent with disorganized thought content/process. Anger and threat statements can reflect strong affect without a formal thought disorder, and asking the time reflects possible disorientation. Externalizing blame (“my daughter…”) is more consistent with poor insight/defensiveness than a disturbance in thought form.

Question 17

A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to?

Accepted Answer

Answer reason: Looking at the infant and then touching the infant aligns with a commonly accepted protective action in many Hispanic/Latino traditions and helps maintain trust and cooperation with care. The other options either introduce disrespectful communication practices, create unnecessary avoidance of normal assessment/handling, or reduce therapeutic engagement with the infant and family. Supporting cultural practices that do not endanger the newborn is consistent with culturally competent nursing care.

Question 18

Which of the following times is a depressed client at highest risk for attempting suicide?

Accepted Answer

Answer reason: Suicide risk can increase early in treatment because psychomotor activation and energy may improve before hopelessness and depressed mood fully resolve. During this window, a client may become more capable of acting on preexisting suicidal thoughts. This makes the first 1–2 weeks after starting antidepressants/therapy a particularly high-risk period that requires close monitoring and safety planning. In contrast, one-to-one observation during admission is a protective measure that reduces opportunity for self-harm rather than representing the peak-risk time.

Question 19

An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she's concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first?

Accepted Answer

Answer reason: The priority nursing action is a focused psychosocial assessment to understand perceptions, expectations, and any negative self-talk before moving to teaching or data collection. Exploring her view of herself helps the nurse identify unrealistic expectations, disordered eating behaviors, or postpartum depression/anxiety indicators that would change the plan of care. Options that collect dietary or weight-trend data or provide pamphlets are appropriate later, but they do not address the immediate need to assess the client’s self-image and emotional state driving the concern.

Question 20

The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be?

Accepted Answer

Answer reason: A healthy goal focuses on recognizing these defenses and using more adaptive coping to manage fear while maintaining self-worth. This option directly reflects the core purpose of defenses—buffering anxiety and protecting self-esteem—without promoting avoidance as the primary strategy. “Avoid conflict and leave unpleasant situations” can reinforce maladaptive avoidance and can worsen anxiety long-term rather than build resilience. The goal is not to eliminate all anxiety, but to manage it in a way that supports functioning and self-concept.

Question 21

Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client?

Accepted Answer

Answer reason: Identifying regression as a defense mechanism reflects insight into coping responses and readiness to examine underlying feelings, which are hallmark tasks of the working phase. In contrast, expressing a desire to be cared for and pampered aligns more with dependency and testing boundaries often seen earlier when roles and trust are still being established. Reconnecting with family can be a positive outcome, but it is less specific to the phase transition than the clear internal insight into defenses.

Question 22

A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"?

Accepted Answer

Answer reason: Suppression is a conscious, intentional decision to postpone thinking or talking about a distressing event to reduce immediate anxiety. This statement reflects deliberate avoidance in the moment while leaving open the possibility of discussing it later, which matches suppression. In contrast, not remembering the event suggests repression or amnesia/dissociation (unconscious blocking), and blaming the other driver reflects projection. Mentioning the mother’s feelings indicates awareness/empathy rather than a defense mechanism aimed at managing the client’s own distress.

Question 23

A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach?

Accepted Answer

Answer reason: Noting affect, eye contact, psychomotor activity, speech patterns, and engagement provides real-time data to guide next steps, including whether to escalate for suicide risk screening. Standardized tools are useful, but they typically follow an initial clinical assessment and rapport-building rather than replacing it at the outset. Alcohol use and family psychiatric history are relevant contributing factors, but they do not provide the most immediate confirmation of the client’s current depressive state or level of impairment.

Question 24

An important goal in the development of a therapeutic inpatient milieu is to?

Accepted Answer

Answer reason: The inpatient setting should help clients try new interpersonal behaviors, receive feedback, and learn limits while maintaining accountability for choices and consequences. Letting clients “decide” unit rules broadly can undermine safety and consistency, since staff must set and enforce boundaries. Suppressing anger is not therapeutic; clients should be helped to express anger appropriately and safely rather than avoid it.

Question 25

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because?

Accepted Answer

Answer reason: A nurse who lacks cultural knowledge may incorrectly pathologize culturally normative behaviors as psychiatric symptoms, leading to inaccurate documentation, biased conclusions, and inappropriate interventions. Culturally informed assessment improves diagnostic accuracy and supports therapeutic communication by distinguishing illness from culturally sanctioned beliefs and practices. “Conventional wisdom” is an unreliable, stereotype-prone basis for interpretation and increases the risk of ethnocentric judgments. Developmental stage knowledge is important but does not address cross-cultural variations in meaning and expression of behavior.

Question 26

Which approach is a priority for the nurse who works with clients from many different cultures?

Accepted Answer

Answer reason: Reflecting on one’s own assumptions helps the nurse avoid stereotyping and supports individualized care based on the client’s values and needs. Learning about common cultures can help but is secondary and risks overgeneralization if not paired with self-reflection. Knowing referral resources or speaking multiple languages may be beneficial, yet they do not address the foundational risk of biased judgment during every patient interaction.

Question 27

A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that?

Accepted Answer

Answer reason: The stem describes pleasant, escapist thoughts about relocation without evidence of loss of reality testing or amnesia, which aligns with normal fantasy rather than a pathological defense. The dissociation option implies a disruptive detachment from awareness used to avoid intolerable affect, which is not supported by the scenario. Conversion and isolation describe different defense mechanisms (physical symptom formation; separation of affect from thought) that do not match the client’s behavior.

Question 28

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?

Accepted Answer

Answer reason: "Good morning. You're in the hospital. I am your nurse Elaine Jones." Reality orientation is most effective when it provides clear, simple, concrete facts about person, place, and situation without testing the client’s memory. This statement calmly identifies the setting and the nurse, giving immediate cues that reduce anxiety and support orientation. Asking whether the client remembers where they are can increase frustration and highlights deficits rather than supporting functioning. An introduction alone is helpful but less complete because it does not orient the client to place.

Question 29

While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?

Accepted Answer

Answer reason: A subjective feeling of impending doom is a classic, high-yield feature that supports panic disorder when occurring with recurrent unexpected panic attacks. Compulsive behavior more strongly suggests obsessive-compulsive disorder rather than panic disorder. Fear of flying reflects a specific phobia, and “predictable episodes” is less consistent with panic disorder, which often involves unexpected attacks.

Question 30

A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of?

Accepted Answer

Answer reason: The statement applies a generalized negative characteristic (“all so hostile”) to an entire racial group, which fits the definition of a stereotype. Discrimination would require an action or unequal treatment based on the belief, not merely the expressed generalization. While prejudice and racism can underlie such beliefs, the specific feature tested here is the broad, unsubstantiated group generalization.

Question 31

A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?

Accepted Answer

Answer reason: An emergency appendectomy involves separation from routine, strict instructions, invasive interventions, and limited ability to influence what is happening, which directly drives this fear. Nursing preparation that offers choices when possible, clear concrete explanations, and involvement in simple decisions helps reduce anxiety by restoring a sense of control. In contrast, fear of body-image change is more characteristic of adolescents, and guilt about hospitalization is more typical in younger children with magical thinking.

Question 32

A client with considerable pain asks: “What is your opinion regarding acupuncture as a drug-free method for alleviating pain?” The nurse responds, “I'd forget about it as those weird non-Western treatments can be scary.” The nurse's response is an example of?

Accepted Answer

Answer reason: ” The nurse dismisses acupuncture by labeling it “weird” and “scary” specifically because it is “non-Western,” reflecting a value judgment centered on Western norms rather than an evidence-based discussion of risks/benefits. This undermines culturally competent care and can damage therapeutic communication by invalidating the client’s beliefs and preferences. Discrimination would involve unequal treatment or denial of care based on group membership, which is not the primary behavior described here.

Question 33

Nurse Tara is caring for a client diagnosed with bulimia nervosa. The most appropriate initial goal for a client is?

Accepted Answer

Answer reason: Bulimia nervosa behaviors are often used as maladaptive coping responses to distress, so early care prioritizes improving insight into emotional and situational triggers. Recognizing anxiety-provoking contexts helps the client anticipate urges to binge/purge and supports development of safer coping strategies in therapy. Goals like stopping buying food or “controlling impulses” are premature and vague because they focus on willpower rather than addressing the underlying affect regulation problem. A rigid meal-frequency rule is not an initial psychosocial goal and may increase preoccupation with control and food-related anxiety, worsening symptoms.

Question 34

A client with schizophrenia reads the advice column in the newspaper daily. When asked why the client is so interested in the advice column, the client replies, This person is my guide and tells me what I must do every day. The nurse would best describe this type of thinking as which of the following?

Accepted Answer

Answer reason: Interpreting a newspaper advice column as a personal “guide” that tells the client what to do reflects misattributing general content as personally meaningful and directive. Grandiose delusions involve exaggerated power/importance, which is not the core belief described here. Thought insertion is a passivity phenomenon where thoughts are experienced as being placed into one’s mind by an external force, which is different from assigning special personal messages to media.

Question 35

The nurse is assessing an aggressive and short tempered man that became a city champion boxer. Which of the following defense mechanisms is he using?

Accepted Answer

Answer reason: Channeling a short temper and aggressive drive into competitive boxing converts the impulse into a structured outlet with rules and goals. This differs from displacement, where anger is redirected to a safer target (e.g., yelling at a family member after conflict at work) rather than transformed into an acceptable pursuit. It also is not projection (attributing one’s feelings to others) or reaction formation (acting opposite to the true impulse).

Question 36

Thumb sucking in adulthood is example of defence mechanism?

Accepted Answer

Answer reason: Thumb sucking is a self-soothing behavior typical of early childhood, so its recurrence in adulthood reflects a return to more immature coping. Suppression and repression involve consciously or unconsciously blocking distressing thoughts rather than reverting behaviorally to an earlier stage. Conversion involves neurologic-like symptoms (e.g., paralysis, blindness) arising from psychological conflict, which does not match the scenario.

Question 37

A nurse is caring for an adolescent who states, "I failed my math exam because the teacher doesn't like athletes." The nurse should identify that the adolescent is using which of the following defense mechanisms?

Accepted Answer

Answer reason: The adolescent avoids responsibility for the poor test performance by blaming the teacher’s supposed bias rather than acknowledging inadequate preparation or skill. This preserves self-esteem by reducing feelings of failure. Reaction formation would involve expressing the opposite feeling, regression would be reverting to earlier behaviors, and identification would be adopting traits of another person.

Question 38

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful?

Accepted Answer

Answer reason: The group setting provides a nonjudgmental environment where members share experiences and normalize struggles, promoting psychological safety. This sense of connectedness can improve coping skills and resilience during cravings, relapse risk, or stress. In contrast, emphasizing independence misses the therapeutic benefit of mutual support and interdependence that is central to most recovery groups.

Question 39

Illusion is?

Accepted Answer

Answer reason: This distinguishes it from a hallucination, which occurs in the absence of any external stimulus. The correct choice explicitly states that a real external stimulus exists and is misinterpreted, matching the definition tested in psychiatric assessment. Options describing perception without stimuli align with hallucinations, while vague statements about “wrong” perception lack the key feature of a real stimulus being present.

Question 40

In following which is a thought disorder ?

Accepted Answer

Answer reason: A delusion is a fixed, false belief that persists despite clear evidence to the contrary, making it a classic disturbance of thought content. By contrast, mannerism and automatism describe abnormal motor/behavioral phenomena, and compulsion is a repetitive behavior or mental act driven by anxiety relief in OCD. Therefore the best match for a thought disorder among the choices is the option reflecting disordered belief content.

Question 41

You are assigned a 69-year-old male resident with a history of bipolar disorder and schizophrenia. Which of the following statements by the resident indicates he is experiencing an acute delusion?

Accepted Answer

Answer reason: "Get out of my room. I know you are the devil dressed up like a priest." A delusion is a fixed, false belief that is not based in reality and is not corrected by evidence, commonly seen in psychotic disorders. This statement reflects a persecutory/religious delusion with misidentification of the caregiver and immediate paranoia, which fits an acute delusional experience. By contrast, hearing a deceased person “talking” is primarily an auditory hallucination (a false sensory perception), not a delusion. The other statements reflect depressive symptoms and a realistic request for sleep help, neither of which indicates psychosis.

Question 42

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect?

Accepted Answer

Answer reason: In many East Asian cultural contexts, sustained direct eye contact with authority figures may be less emphasized, whereas it is commonly expected in mainstream U.S. communication. The daughter’s use of direct eye contact while actively questioning suggests she is using dominant-culture interaction patterns rather than those traditionally associated with her family’s heritage culture. Prejudice, stereotyping, and ethnocentrism describe attitudes or judgments about groups and do not best explain a behavioral shift in communication style.

Question 43

Psychoanalytic therapy was developed by?

Accepted Answer

Answer reason: The originator formalized techniques such as free association, interpretation of dreams, and analysis of transference as core methods of treatment. Among the options, the historically recognized developer of psychoanalytic therapy is Freud. A common distractor is Jacobson, who is associated with progressive muscle relaxation rather than insight-oriented psychoanalysis.

Question 44

Which of the following is not an appropriate nursing diagnosis for a patient with bipolar disorder?

Accepted Answer

Answer reason: During mania, poor judgment, hyperactivity, impulsivity, and decreased sleep raise safety concerns, making injury risk a common and high-priority diagnosis. Appetite changes, distractibility, and high activity can lead to inadequate intake or weight changes, supporting an imbalanced nutrition diagnosis. Thought disturbance can occur with manic or severe depressive episodes (e.g., racing thoughts, impaired concentration, possible psychosis), supporting disturbed thought process; infection risk is not a primary diagnosis tied to bipolar disorder unless another condition or treatment-related factor is present.

Question 45

The nurse is assessing a client experiencing psychosis. The client states, "I am convinced my wife and brother-in-law want to kill me." The nurse interprets this statement as a?

Accepted Answer

Answer reason: A persecutory delusion is a fixed, false belief that others intend harm, are plotting against the person, or are trying to injure or kill them. The client’s conviction that family members want to kill him reflects threat-focused misinterpretation consistent with paranoia rather than mood-congruent or self-referential thinking. A delusion of reference involves believing neutral events/messages are directed specifically at the client, which is not described here. Grandiose and erotomanic delusions center on exaggerated importance/power or being loved by someone (often of higher status), neither of which fits the content of the statement.

Question 46

The client is unhappy the current nurse has set limits on her behavior. The client yells, “You’re the only one being mean to me. You are evil!” The nurse recognizes this behavior as?

Accepted Answer

Answer reason: By labeling the nurse as “mean” and “evil,” the client is devaluing one caregiver, which can be paired with idealizing others to manage anxiety and maintain control. This pattern is common in certain personality disorders and is clinically important because it can undermine team cohesion unless staff communicate consistently. The other options do not fit: hallucinations are sensory perceptions without stimuli, and grandiose delusions involve inflated power/importance, not staff-splitting dynamics.

Question 47

Which behavior is consistent with the diagnosis of conduct disorder in a child?

Accepted Answer

Answer reason: Intentional harm to animals is a classic aggressive behavior that directly fits this diagnostic pattern. Enuresis is more consistent with elimination disorders or stress/trauma-related regression rather than deliberate rule-breaking. Fear of going to school points toward separation anxiety or school phobia, and suicidal ideation more commonly reflects depressive or other mood disorders rather than the core features of conduct disorder.

Question 48

In every household, members have to decide the ways in which work and responsibilities will be divided and shared. Different roles include?

Accepted Answer

Answer reason: Family role theory describes common functional positions that organize household responsibilities (e.g., who earns income, manages resources, and ensures basic needs are met). The provider role specifically refers to supplying financial or material support to the family system, which directly aligns with the stem’s focus on dividing work and responsibilities. By contrast, gender is an attribute that can influence expectations but is not itself a household “role,” and student is a life status that may or may not define household responsibility-sharing. “Bidder” is not a recognized family-role category in standard nursing psychosocial frameworks.

Question 49

Which religious group may decline unnecessary health care procedures on Shabbat?

Accepted Answer

Answer reason: Shabbat (the Sabbath) is a weekly day of rest in Judaism during which many observant individuals avoid certain forms of “work,” which can include non-urgent medical procedures. In clinical care, elective or unnecessary interventions may be deferred until after Shabbat, while life-saving care is permitted and expected because preservation of life overrides Sabbath restrictions (pikuach nefesh). This question tests culturally competent nursing care by anticipating and respecting potential religious constraints on timing of nonessential treatments. A common distractor is Christian Scientists, who may refuse medical treatment broadly based on healing beliefs, but that refusal is not specifically tied to Shabbat observance.

Question 50

In the Buddhist religion, the use of drugs and alcohol is?

Accepted Answer

Answer reason: Buddhism emphasizes maintaining mindfulness and avoiding substances that cause intoxication because they impair judgment and awareness. This aligns with the Fifth Precept, which counsels abstaining from intoxicants that lead to heedlessness. Therefore, substance use is generally viewed as something to avoid rather than promote. Options implying necessity, encouragement, or no guidance conflict with this widely taught ethical framework and would lead to inaccurate culturally competent care assumptions.

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

Mental Health Concepts NCLEX Practice Test

Continue Learning