Question 1

A client 12 hours postpartum is anxious and tearful. She says, "I don't think I can handle this baby." What is the best initial nursing response?

Accepted Answer

Answer reason: The best initial response is an open-ended, nonjudgmental statement that encourages the client to elaborate, allowing the nurse to assess emotions, coping, and safety. "Tell me more about how you're feeling" uses therapeutic communication and helps differentiate normal postpartum "baby blues" from more serious depression without prematurely labeling. Telling her she should be happy is dismissive and can increase guilt and shut down communication. Notifying the provider may be appropriate after further assessment, but the initial nursing action is to explore and assess first.
Category reason: This item tests the nurse’s use of therapeutic communication to assess a postpartum client’s emotional state and coping, which is a psychosocial nursing judgment rather than foundational biomedical knowledge.

Question 2

A client with schizophrenia is pacing the hallway, talking loudly to himself. What is the nurse's best action?

Accepted Answer

Answer reason: A client talking loudly to himself may be responding to internal stimuli (e.g., hallucinations), and the nurse should use calm, nonthreatening therapeutic communication to assess what the client is experiencing and ensure safety. Asking what he is saying helps gather data, builds rapport, and can guide de-escalation while maintaining the client’s dignity. Commanding him to stop can increase agitation, calling security is not indicated without imminent risk, and ignoring misses an opportunity to assess for distress or escalation.
Category reason: The question tests a nurse’s immediate communication and de-escalation approach to a client exhibiting possible psychotic symptoms, which is primarily a psychosocial nursing intervention and therapeutic communication decision.

Question 3

A new mother reports frequent crying, feeling overwhelmed, and trouble sleeping. What response by the nurse is most appropriate?

Accepted Answer

Answer reason: The most appropriate nursing response uses therapeutic communication: it normalizes common postpartum emotions without dismissing them and invites the client to explore coping and supports. Option B is open-ended and assessment-focused, allowing the nurse to further evaluate severity, duration, safety (including suicidal thoughts), and need for referral. Option A prematurely labels and refers without first assessing, while C is judgmental and can increase guilt. Option D provides non-evidence-based, potentially isolating advice and does not address the client’s emotional needs.
Category reason: This question tests the nurse’s communication and psychosocial support response to postpartum emotional symptoms, which is a patient-care nursing judgment topic rather than foundational biomedical science.

Question 4

Which is not a principle of psychiatric nursing?

Accepted Answer

Answer reason: Core principles of psychiatric nursing include acceptance, nonjudgmental attitudes, and fostering a therapeutic milieu that supports patient growth and autonomy. A judgmental attitude increases stigma, reduces trust, and interferes with development of a therapeutic nurse–patient relationship. Promoting self-care is consistent with psychiatric rehabilitation and recovery-oriented care, and providing a therapeutic environment is a standard component of mental health nursing.
Category reason: The item tests foundational mental health nursing principles that support building a therapeutic nurse–patient relationship (e.g., acceptance and nonjudgmental stance), which aligns with Therapeutic Communication in Psychosocial Integrity.

Question 5

Nurse Patrick is interviewing a newly admitted psychiatric client. Which nursing statement is an example of offering a “general lead”?

Accepted Answer

Answer reason: A general lead is a therapeutic communication technique that encourages the client to continue talking without directing the content, helping the client set the pace and focus. "Yes, I see. Go on." is neutral, nonjudgmental, and invites elaboration. The other options are more directive and focused (closed-ended or structured questioning), which can limit spontaneous sharing and exploration early in an interview.
Category reason: The question tests a nurse’s use of therapeutic communication techniques during a psychiatric interview, which is a psychosocial nursing skill under Therapeutic Communication.

Question 6

The nurse says, “Can you tell me more about how you’re feeling?” The therapeutic communication technique that she is using is called?

Accepted Answer

Answer reason: “Can you tell me more about how you’re feeling?” invites the client to elaborate in their own words, which is characteristic of an open-ended question. Open-ended questions facilitate exploration of feelings and provide richer assessment data. Closed-ended questions typically yield yes/no or brief factual responses. Clarifying and active listening are related techniques but are not the primary method demonstrated by this phrasing.
Category reason: The item tests a nurse’s use of therapeutic communication to support assessment and coping, which falls under Psychosocial Integrity—Therapeutic Communication.

Question 7

A nurse is caring for a client experiencing auditory hallucinations. The client says, "The voices are telling me I'm worthless." What is the best response by the nurse?

Accepted Answer

Answer reason: "I don't hear anything, but I understand that's real for you." This response uses therapeutic communication by acknowledging the client’s experience without validating the hallucination as factual. It presents reality (“I don’t hear anything”) while conveying empathy and support, which helps maintain trust and reduces defensiveness. The other options either dismiss the experience, attempt premature distraction, or argue/command the client, which can increase distress and worsen engagement.
Category reason: This item tests the nurse’s best therapeutic response to a client reporting auditory hallucinations, focusing on communication techniques and emotional support rather than biomedical mechanisms, fitting Therapeutic Communication under Psychosocial Integrity.

Question 8

During a home visit, a patient tells the nurse, "I haven’t been able to sleep for the past couple of nights." Which of the following responses by the nurse best demonstrates therapeutic communication?

Accepted Answer

Answer reason: C. "Would you like to talk about what’s been keeping you awake?" This response is open-ended and invites the patient to elaborate, promoting exploration of contributing factors (stress, pain, environment, anxiety) without judgment. It demonstrates empathy and focuses on the patient’s experience while gathering assessment data. In contrast, “why” questions can feel accusatory, labeling the patient as depressed is an unfounded assumption, and self-disclosure shifts the focus away from the patient.
Category reason: The item tests the nurse’s use of communication techniques (open-ended questioning, avoiding assumptions, maintaining patient focus) to build rapport and assess concerns, which is Therapeutic Communication under Psychosocial Integrity.

Question 9

A client with schizophrenia tells the nurse, “I hear voices telling me that I’m worthless.” What is the best response by the nurse?

Accepted Answer

Answer reason: “I don’t hear anything, but I understand this is distressing for you.” This response uses therapeutic communication by acknowledging the client’s feelings without validating the hallucination as real. It presents reality (“I don’t hear anything”) while offering empathy and support, which helps build trust and reduces anxiety. Telling the client to ignore the voices or giving reassurance can minimize their experience, and probing “why” can increase defensiveness or reinforce the delusion/hallucination content.
Category reason: The question tests the nurse’s best communication response to a client experiencing auditory hallucinations, which is a patient-care interaction focused on therapeutic communication in mental health nursing.

Question 10

During a group therapy session, a client begins to cry and says, "I feel like nobody understands me." What is the nurse's most therapeutic response?

Accepted Answer

Answer reason: Why do you feel that way? This response uses therapeutic communication by encouraging the client to explore and verbalize feelings, which helps clarify the emotion behind the statement and promotes insight. It is open-ended and patient-centered, rather than minimizing or redirecting emotions. The other options either offer premature reassurance (C) or discourage emotional expression (D); (A) is supportive but less therapeutic than facilitating exploration of the client’s feelings.
Category reason: The question asks for the nurse’s most therapeutic verbal response in a mental health group setting, which directly tests therapeutic communication skills within Psychosocial Integrity.

Question 11

A nurse should always maintain eye contact with anxious patients.?

Accepted Answer

Answer reason: False Maintaining eye contact can be therapeutic, but it should not be done “always,” because intense or prolonged eye contact may increase anxiety, feel confrontational, or be culturally inappropriate. Therapeutic communication requires observing the patient’s comfort level and using intermittent, nonthreatening eye contact along with a calm tone and supportive presence. The best approach is individualized, respectful, and adaptable rather than absolute.
Category reason: This item tests appropriate nurse–patient interaction techniques for an anxious patient, which is a core Therapeutic Communication skill within Psychosocial Integrity.

Question 12

A patient with major depressive disorder reports having no energy, difficulty sleeping, and loss of appetite. Which statement by the nurse is therapeutic?

Accepted Answer

Answer reason: "I can see that this is really difficult for you. Can you tell me more?" This response uses empathy and an open-ended question to encourage the patient to express feelings and elaborate, which supports therapeutic communication. It validates the patient’s experience without minimizing symptoms or giving premature advice. The other options offer unsolicited solutions (exercise, positive thinking, stimulants/vitamins) that can sound dismissive and may shut down further sharing.
Category reason: The question asks which nurse statement is therapeutic in a mental health interaction, focusing on communication techniques rather than biomedical facts, so it fits Therapeutic Communication under Psychosocial Integrity.

Question 13

A patient diagnosed with schizophrenia should be encouraged to isolate themselves.?

Accepted Answer

Answer reason: False Encouraging isolation can worsen negative symptoms (e.g., social withdrawal, anhedonia) and functional decline, and it may increase risk for depression and suicidality. Nursing care generally promotes structured social interaction, engagement in activities, and supportive milieu therapy at a tolerable pace to build coping and social skills. Interventions emphasize therapeutic communication, reality-based interaction, and connecting the patient with community supports rather than reinforcing withdrawal.
Category reason: This item tests an appropriate nursing approach to psychosocial care—whether to encourage social isolation versus therapeutic engagement—so it fits Psychosocial Integrity with a focus on therapeutic communication and interaction strategies.

Question 14

True or False Nurses should always maintain strict eye contact with psychiatric patients.?

Accepted Answer

Answer reason: False Strict or prolonged eye contact can be perceived as threatening, intrusive, or confrontational, particularly for clients who are anxious, paranoid, traumatized, or experiencing psychosis. Therapeutic communication uses culturally sensitive, nonthreatening eye contact and respects personal space and client cues. The nurse should maintain a calm demeanor and adjust eye contact to support rapport, reduce agitation, and promote safety.
Category reason: This item tests appropriate nurse communication behavior with psychiatric clients, focusing on building rapport and reducing escalation, which fits Therapeutic Communication under Psychosocial Integrity.

Question 15

The nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which?

Accepted Answer

Answer reason: C. Sit beside the client in silence and verbalize occasional open-ended questions. In catatonic stupor, the priority is a calm, nonthreatening presence and supportive communication that does not overwhelm the client. Silence with brief, open-ended prompts reduces pressure, supports trust, and allows any response without demanding immediate verbalization. Leaving the client alone increases isolation and risk for complications related to immobility, while pushing direct questioning or placing the client in a stimulating group setting can increase anxiety and is not therapeutic or safe.
Category reason: This item tests the nurse’s choice of communication approach and environmental interaction for a patient in a severe psychiatric state, which is primarily therapeutic communication in psychosocial nursing care.

Question 16

Assertive communication means

Accepted Answer

Answer reason: Assertive communication involves stating needs, feelings, and boundaries directly while maintaining respect for others’ rights and perspectives. It contrasts with aggressive styles that violate others’ rights and with passive/passive-aggressive styles that avoid direct expression. This approach supports therapeutic relationships, reduces misunderstandings, and helps manage conflict constructively.
Category reason: This question tests principles of interpersonal/therapeutic communication used in nursing interactions, which falls under Psychosocial Integrity—Therapeutic Communication.

Question 17

A patient appears anxious about an upcoming procedure. Which of the following responses by the nurse will reduce this patient's anxiety?

Accepted Answer

Answer reason: ?" This is an open-ended, therapeutic communication technique that invites the patient to express specific fears and concerns, which helps decrease anxiety through emotional ventilation and clarification. It also allows the nurse to assess the patient’s understanding and tailor teaching or coping strategies to the actual source of worry. The other options either minimize feelings, shift responsibility without addressing emotions, or offer distraction without first exploring the patient’s needs.
Category reason: The item tests the nurse’s use of therapeutic communication to support a patient experiencing pre-procedure anxiety, which is a psychosocial coping/adaptation intervention rather than biomedical knowledge.

Question 18

A patient's unresolved feelings related to loss would be MOST LIKELY observed during which phase of the therapeutic nurse-patient relationship?

Accepted Answer

Answer reason: During the termination phase, the nurse–patient relationship ends, which commonly triggers feelings of separation and can reactivate or reveal unresolved grief and loss issues. Patients may show increased anxiety, sadness, anger, or regression as they anticipate the end of support and attachment. A key nursing focus here is helping the patient review progress, acknowledge feelings about ending, and plan for continued coping and resources after discharge.
Category reason: This question tests understanding of the phases of the therapeutic nurse–patient relationship and the communication needs that arise in each phase, which falls under Therapeutic Communication in Psychosocial Integrity.

Question 19

A nurse on a mental health unit is admitting a client who is anxious and tells the nurse, "I hear voices telling me what to do." Which of the following actions should the nurse take?

Accepted Answer

Answer reason: D. Ask the client what the voices are saying Assessing the content of command hallucinations is a priority safety intervention because it helps determine whether the client is being directed to harm self or others. A calm, nonjudgmental approach that acknowledges the experience without validating it supports rapport and allows risk assessment. Dismissing the experience can increase distrust and anxiety, while unsolicited touch can escalate agitation. Directing the client away without assessment delays identification of immediate danger and needed interventions.
Category reason: This item tests a nurse’s immediate communication and safety-focused assessment response to auditory hallucinations, which is a patient-care judgment skill within Therapeutic Communication.

Question 20

You are working with a client who has dentures but does not wear them. When questioned about the reason for not wearing the dentures, the client states that it makes him feel old. Which of the following responses would be best?

Accepted Answer

Answer reason: k." This response acknowledges the concern indirectly while providing factual, health-focused education that can motivate adherence without arguing about the client’s feelings. It avoids judgment, reassurance, or focusing on appearance, which can invalidate the client’s stated concern about feeling old. Denture use helps maintain oral function and can reduce unwanted changes of the oral tissues over time, supporting the client’s long-term comfort and nutrition.
Category reason: This item tests the nurse’s choice of the most therapeutic, client-supportive communication response to a psychosocial concern (feeling old) while promoting appropriate self-care.

Question 21

"I guess I'll never be able to eat ice cream again", says the client to the nurse. What would be the best response by the nurse to this statement?

Accepted Answer

Answer reason: ?" This is a therapeutic communication technique (restating/paraphrasing) that invites the client to clarify feelings and meaning without judgment. It demonstrates active listening and encourages further discussion, which supports coping and adaptation. The other options either change the subject with false reassurance, ask a potentially challenging “why” question, or respond judgmentally and can shut down communication.
Category reason: The item tests the nurse’s best verbal response to a client statement using therapeutic communication skills, which is an NCLEX patient-care judgment area under Psychosocial Integrity.

Question 22

A nurse is making a plan of care for a client brought to the mental health unit with a diagnosis of obsessive-compulsive disorder who is experiencing severe anxiety. What is the nurse’s priority intervention in the plan of care?

Accepted Answer

Answer reason: In severe anxiety, the client’s ability to process information and engage in problem-solving is reduced, so the immediate priority is to create safety and rapport. A therapeutic relationship is the foundation for further assessment, anxiety-reduction strategies, and collaboration around managing compulsions without escalating distress. Education and encouraging participation are important but are less effective until anxiety is stabilized and trust is established. Monitoring repetitive behaviors is supportive, but it does not address the primary need for therapeutic engagement that enables subsequent interventions.
Category reason: This is a mental health nursing priority/intervention question focused on building rapport and using therapeutic communication to manage anxiety in OCD, which aligns with Psychosocial Integrity.

Question 23

Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?

Accepted Answer

Answer reason: ?" This response uses therapeutic communication by making an observation about the client’s affect and inviting him to verbalize concerns before surgery. Open-ended exploration helps reduce anxiety, builds trust, and provides the nurse an opportunity to assess specific fears and misconceptions. The other options either change the subject, dismiss the client’s feelings, or use judgmental/critical language, which can shut down communication.
Category reason: This is primarily a nurse–patient communication scenario focused on assessing and supporting preoperative anxiety, which best fits Therapeutic Communication under Psychosocial Integrity.

Question 24

First phase of interpersonal relationship is known as?

Accepted Answer

Answer reason: This refers to Peplau’s nurse–client interpersonal relationship model, in which the initial phase focuses on establishing trust, clarifying roles, setting expectations, and identifying the client’s needs and problems. The working and termination phases occur later, after rapport and goals are established. “Identification” is not the first phase in as commonly taught in nursing communication frameworks.
Category reason: This question tests knowledge of phases of the nurse–client relationship and communication process, which is a core therapeutic communication concept within Psychosocial Integrity.

Question 25

A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: School-age children benefit from simple, honest, concrete explanations given shortly before the procedure to reduce anxiety and build trust. Using truthful, age-appropriate language prepares the child for what to expect and supports cooperation. Routine use of a restrictive restraint is not appropriate unless necessary for safety and should be a last resort with proper orders/policy. Parents generally should be offered the option to stay, as their presence can provide comfort and decrease distress.
Category reason: This item tests a nurse’s communication and preparation of a child for a procedure to reduce anxiety and promote cooperation, which fits Therapeutic Communication within Psychosocial Integrity.

Question 26

A nursing preceptor is giving feedback to a new nurse who currently is being oriented. Her preceptor suggests a better method of interacting with a family member by saying, "You might want to be cognizant of your non-verbal behaviors when talking with clients. Rather than continuing to chart when you are talking with an American family, stop charting, move closer to the family and client, look at them during the conversation, and take time to let them share their concerns." This preceptor is giving advice about?

Accepted Answer

Answer reason: The feedback focuses on using effective nonverbal behaviors—stopping charting, moving closer, maintaining eye contact, and allowing time for concerns—which are core elements of therapeutic communication. These behaviors promote rapport, convey attention and respect, and improve the client/family’s willingness to share information. The emphasis is on interaction technique rather than message wording alone (clarity), outward appearance (image), or the speaker’s purpose (intention).
Category reason: This item tests how the nurse should communicate and engage with a client/family using therapeutic nonverbal strategies, which is a patient-care communication skill under Psychosocial Integrity.

Question 27

The LPN/LVN enters the room of a patient who is angry and yells, "I asked 5 minutes ago for my pain medication. I'm going to call the CEO of the hospital if you don't get it for me." Which statement by the nurse demonstrates intellectual empathy?

Accepted Answer

Answer reason: n." It acknowledges the client’s feelings and perspective without being defensive or blaming, which helps de-escalate anger. It validates the distress (pain and frustration) and conveys understanding, supporting a therapeutic nurse-client relationship. The other statements either justify delays, compare the client to others, or escalate the conflict by focusing on administrative threats rather than the client’s experience.
Category reason: This item tests the nurse’s use of empathy and de-escalation language in response to an angry client, which is a core Therapeutic Communication competency.

Question 28

Mr. Pablo, diagnosed with Bladder Cancer, is scheduled for a cystectomy with the creation of an ileal conduit in the morning. He is wringing his hands and pacing the floor when the nurse enters his room. What is the best approach?

Accepted Answer

Answer reason: ?" This response uses therapeutic communication by making an observation about the patient’s affect/behavior and inviting him to express concerns about the upcoming procedure. Open-ended exploration helps reduce anxiety, builds rapport, and allows the nurse to assess specific fears (e.g., body image changes, stoma care, prognosis) and provide targeted education/support. The other options either change the subject, abandon the patient, or use judgmental/humorous phrasing that can shut down communication.
Category reason: The question tests the nurse’s best verbal response to an anxious preoperative patient, emphasizing communication techniques to assess and support coping, which fits Therapeutic Communication.

Question 29

A client with schizophrenia reports auditory hallucinations. Which response by the nurse is most therapeutic?

Accepted Answer

Answer reason: ?" This response acknowledges the client’s feelings and invites exploration of the hallucinations, which supports rapport and assessment of content, severity, and potential safety risk (e.g., command hallucinations). It avoids validating the hallucination as real while still validating the emotional experience. The other options dismiss, minimize, or give non-therapeutic advice, which can increase anxiety and reduce trust.
Category reason: This question tests the nurse’s best therapeutic communication response to a psychiatric symptom (auditory hallucinations), which is a psychosocial nursing judgment.

Question 30

A client with depression reports hopelessness. Which response by the nurse is most appropriate?

Accepted Answer

Answer reason: ?" This response uses therapeutic communication by reflecting the client’s feeling and inviting elaboration with an open-ended question. It validates the client’s experience and promotes further assessment of mood, coping, and potential safety concerns without minimizing or offering false reassurance. The other options either dismiss the emotion, normalize it in a way that shuts down discussion, or redirect away from the client’s stated concern.
Category reason: This item tests the nurse’s communication approach to a mental health symptom (hopelessness) and selecting a therapeutic response, which is a patient-care judgment skill under Therapeutic Communication.

Question 31

A 16-year-old client who underwent emergency surgery for a ruptured appendix refuses to allow the nurse to change the abdominal dressing, saying, “Go away. There is nothing wrong with this dressing.” Which would be the best nursing response?

Accepted Answer

Answer reason: This response addresses adolescent needs for privacy, modesty, and control while still attempting to complete necessary postoperative wound care. It uses therapeutic communication by offering a concrete plan to reduce embarrassment and by seeking permission, which supports autonomy and cooperation. The other responses are defensive, minimize the client’s feelings, or use coercion/withholding visitation, which can increase resistance and undermine trust.
Category reason: This item tests the nurse’s best verbal response to a resistant adolescent, emphasizing privacy, autonomy, and building cooperation—core elements of therapeutic communication in patient care.

Question 32

Which of the following are therapeutic communication techniques?

Accepted Answer

Answer reason: This item is a select-all-that-apply question, so it requires choosing multiple correct therapeutic techniques rather than a single best answer. Therapeutic communication commonly includes reflecting feelings, clarifying, and offering silence, while giving advice and agreeing are generally non-therapeutic because they can impose the nurse’s values or shut down exploration. A single-letter answer cannot capture the required response set safely.
Category reason: This question tests nurse-client interaction skills and identification of appropriate communication responses in mental health settings, which maps to Therapeutic Communication under Psychosocial Integrity.

Question 33

A client with schizophrenia tells the nurse, “The voices are telling me to hurt myself.” What is the nurse’s best response?

Accepted Answer

Answer reason: This response acknowledges distress, conveys safety, and uses therapeutic communication without validating the hallucination content. It helps de-escalate and opens assessment of suicidal ideation/intent and coping, which is urgent when command hallucinations involve self-harm. The other options are nontherapeutic (dismissive, judgmental “why” question) or overly directive without immediate safety-focused assessment.
Category reason: This item tests the nurse’s communication and immediate response to a client experiencing command hallucinations, emphasizing safety-focused therapeutic interaction rather than pathophysiology knowledge.

Question 34

A nurse is caring for a patient with major depressive disorder who states, “I feel like I’m a burden to everyone.” What is the best response by the nurse?

Accepted Answer

Answer reason: This uses therapeutic communication by offering presence and inviting the patient to elaborate, which validates feelings and promotes further assessment. It avoids minimizing, giving false reassurance, or redirecting to “positive thinking,” all of which can shut down communication in depression. It also opens the door to evaluate severity (including suicidal ideation) and identify needs for support and safety planning.
Category reason: The question tests the nurse’s best verbal response to a depressive statement, emphasizing communication techniques that support coping and further assessment rather than biomedical knowledge.

Question 35

A patient with generalized anxiety disorder tells the nurse, “I can’t stop worrying about everything. It’s exhausting.” Which of the following is the most therapeutic response by the nurse?

Accepted Answer

Answer reason: C. It must be difficult to feel that way. Tell me more about what’s worrying you. This response uses empathy and reflection, validating the patient’s experience while inviting them to elaborate, which promotes trust and further assessment. Open-ended exploration helps identify triggers, thought patterns, and severity without judging or minimizing the symptoms. The other options either give premature advice, ask a potentially blaming “why” question, or provide false reassurance that can shut down communication.
Category reason: This item tests the nurse’s best therapeutic response to a patient expressing anxiety, emphasizing communication techniques to support coping and assessment, which fits Therapeutic Communication under Psychosocial Integrity.

Question 36

While caring for a child who has been injured, what nursing intervention is consistent with a family-centered approach?

Accepted Answer

Answer reason: C. Allowing family to participate in the care of the patient Family-centered care emphasizes collaboration with the family as partners and supports their involvement in appropriate aspects of care (comforting the child, assisting with routines, being present during procedures when safe). This promotes the child’s emotional security, reduces anxiety, and improves communication and adherence to the plan of care. Excluding the family or restricting information undermines partnership, while placing all decisions solely on the family is inappropriate because clinical decisions require shared decision-making and professional accountability.
Category reason: This question tests a nursing intervention that supports family involvement and communication during pediatric care, which is a psychosocial nursing care concept rather than foundational biomedical science.

Question 37

How would you provide support for a 16-year-old patient to reduce anxiety during physical examination?

Accepted Answer

Answer reason: Adolescents may experience significant anxiety during a physical exam due to vulnerability and fear of judgment. A calm, supportive nurse presence provides reassurance, encourages expression of concerns, and helps the patient feel emotionally safe, which reduces anxiety and improves cooperation. This is an active therapeutic communication intervention that also supports trust and rapport. While privacy is important, it is more about dignity than direct emotional support, and not intervening is inappropriate nursing care.
Category reason: This question focuses on a nursing intervention to reduce anxiety through supportive presence and communication during an exam, which is best categorized under Therapeutic Communication in Psychosocial Integrity.

Question 38

A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?

Accepted Answer

Answer reason: B. Identify the client's perception of her mental health status During an initial mental health interview, the nurse’s priority is to establish rapport and perform a client-centered assessment by exploring the client’s understanding, concerns, and goals. Eliciting the client’s perception guides appropriate follow-up questions, helps identify readiness for change, and supports a therapeutic alliance. The other actions (coordination with services, involving family, teaching) are important but should follow after a clear assessment of the client’s perspective, consent, and immediate needs/safety.
Category reason: This item tests priority communication and assessment actions during an initial mental health interview, which primarily involves building rapport and gathering subjective data—core elements of Therapeutic Communication within Psychosocial Integrity.

Question 39

While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

Accepted Answer

Answer reason: A. The nurse' ability to directly observe the client's nonverbal communication is limited while note taking. Note-taking can reduce eye contact and attention to body language, facial expression, and other nonverbal cues that are essential for accurately interpreting the client’s message. Excessive writing can also disrupt rapport and make the client feel less heard, potentially limiting disclosure. Documentation is important, but it should be balanced with active listening, observation, and periodic brief notes rather than continuous writing.
Category reason: This item tests interviewing technique and how nurse behaviors affect rapport, observation of nonverbal cues, and communication effectiveness, which aligns with Therapeutic Communication.

Question 40

A 28-year-old patient with schizophrenia hears voices and is agitated at 1:20 PM on June 23, 2025. What is the nurse’s priority action?

Accepted Answer

Answer reason: The safest first-line nursing priority for acute agitation is to reduce escalation using calm, nonthreatening verbal techniques, active listening, and setting clear limits while maintaining a safe environment. Medications can be appropriate if de-escalation fails or there is imminent risk, but giving a sedative immediately bypasses less restrictive measures and requires assessment and monitoring. Physical restraints are the last resort due to risk of injury and should be used only when the patient poses immediate danger and other measures are ineffective. Ignoring escalating agitation increases risk of harm to the patient and others.
Category reason: This question tests the nurse’s immediate behavioral intervention for an agitated psychiatric patient, emphasizing de-escalation and communication strategies in a clinical care situation, which fits Therapeutic Communication under Psychosocial Integrity.

Question 41

A patient with major depressive disorder refuses to eat at 1:25 PM today. What should the nurse do first?

Accepted Answer

Answer reason: Refusal to eat in major depressive disorder can reflect hopelessness, low energy, anxiety, or suicidal ideation; the priority is to assess underlying emotional state and immediate safety needs. Therapeutic communication helps identify barriers to intake and allows the nurse to intervene with supportive strategies and appropriate referrals. Force-feeding is unsafe and violates client rights unless there is an emergency legal/medical indication. Medication is not an immediate solution for an acute refusal, and ignoring/documenting without assessment delays needed care.
Category reason: This item tests the nurse’s first action in response to a behavioral health symptom using supportive assessment and communication rather than biomedical facts, fitting Psychosocial Integrity—Therapeutic Communication.

Question 42

Cloze: A nurse is using therapeutic communication with a patient who says, "I'm worthless." The best response is?

Accepted Answer

Answer reason: ?" This is an open-ended, nonjudgmental invitation that encourages the patient to explore feelings and underlying causes, supporting assessment and rapport. It avoids minimizing the patient’s statement or offering premature reassurance, which can shut down communication. It also helps the nurse assess for depression, hopelessness, and potential self-harm risk while validating the patient’s experience.
Category reason: This item tests the nurse’s use of therapeutic communication techniques (open-ended questions, exploration of feelings) in response to a maladaptive self-statement, which falls under Psychosocial Integrity → Coping and Adaptation → Therapeutic Communication.

Question 43

A nurse observes a client in the psychiatric unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?

Accepted Answer

Answer reason: s." This response acknowledges the client’s feelings while presenting reality without arguing, which helps maintain rapport and reduces escalation. It also avoids validating the hallucination, while opening the door for further assessment of command hallucinations and suicide risk. The other responses either reinforce the hallucination, dismiss the client’s experience, or minimize the danger of self-harm commands.
Category reason: This is a psychiatric nursing communication scenario requiring a therapeutic response to auditory hallucinations and potential self-harm, which is tested under Therapeutic Communication.

Question 44

A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse?

Accepted Answer

Answer reason: ?" This is an open-ended, nonjudgmental question that helps the client explore thoughts and triggers associated with anger, which is central to managing aggressive behavior. It avoids “why” phrasing that can sound accusatory and increase defensiveness. It also focuses on assessment and insight-building rather than prematurely giving advice or shifting attention to others’ feelings. Exploring the client’s cognitions supports therapeutic communication and identification of maladaptive patterns to address in treatment.
Category reason: The item tests the nurse’s choice of an appropriate, nonjudgmental interviewing statement to facilitate client self-exploration, which is a core therapeutic communication skill within psychosocial nursing care.

Question 45

Non-verbal communication-

Accepted Answer

Answer reason: Nonverbal communication refers to messages sent without words, including facial expressions, posture, gestures, eye contact, and tone. Facial expressions convey emotions and attitudes and often complement or contradict spoken language. Written communication, talking face-to-face (verbal plus nonverbal), and telephone conversations primarily involve verbal content, with the phone lacking visual nonverbal cues.
Category reason: This item tests recognizing forms of communication used in nurse–client interactions, which is a core Therapeutic Communication concept in psychosocial nursing care.

Question 46

A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?

Accepted Answer

Answer reason: D. Encourage the client to express her feelings regarding the upcoming procedure. The behavior is likely anxiety-driven and intensified by anticipation of an invasive procedure; focusing on control and perfectionism is a maladaptive coping strategy. A therapeutic response is to explore underlying feelings and concerns, which can reduce anxiety and improve coping. Challenging the behavior as “wrong,” teaching control strategies in the moment, or interrogating the behavior may increase defensiveness and anxiety rather than address the precipitating stressor.
Category reason: This item tests a nurse’s therapeutic communication and psychosocial intervention to address anxiety-related behaviors in a patient care situation, which aligns with Psychosocial Integrity—Therapeutic Communication.

Question 47

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the coming up the next day. Which intervention is most important for the RN to implement during the admission process?

Accepted Answer

Answer reason: During acute anxiety, the nurse’s priority is to reduce stimulation and convey safety through a calm, structured, supportive presence. A matter-of-fact approach helps the client feel contained and decreases escalation, enabling further assessment and teaching later. Asking “why” can feel confrontational and may increase anxiety, while teaching coping skills is not the immediate priority until anxiety is reduced. PRN sedation is not first-line without attempting nonpharmacologic de-escalation and assessing contributing factors and safety.
Category reason: This question tests a nursing communication and de-escalation intervention for an anxious psychiatric client during admission, which is primarily therapeutic communication within psychosocial nursing care.

Question 48

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Accepted Answer

Answer reason: Assessment comes before implementing interventions or making assumptions, and observing communication patterns helps determine whether limited eye contact is situational, anxiety-related, or consistent with the client’s usual interactions. This approach is client-centered, nonjudgmental, and supports culturally competent care while preserving rapport. Reading articles or asking staff may be helpful later, but they are indirect sources and do not replace assessing the individual client. Simply accepting the behavior without assessment risks missing other causes (e.g., fear, depression, cognitive issues, or interpersonal conflict).
Category reason: This question tests culturally sensitive nurse-client communication and the initial therapeutic approach during an interview, which fits Therapeutic Communication within Psychosocial Integrity.

Question 49

Which of the following interventions will likely ensure compliance of Mariah?

Accepted Answer

Answer reason: Collaboratively tailoring the plan to the client’s preferences increases autonomy, acceptability, and sustained adherence. In pregnancy, meeting nutritional needs is essential, but behavior change is most effective when recommendations are realistic and culturally/personal preference–sensitive. Repeated generic counseling or fear-based warnings may trigger resistance, and simply allowing rejection does not promote engagement or compliance.
Category reason: This item tests a nursing intervention to promote adherence through a collaborative, client-centered approach, aligning with therapeutic communication and behavior-change strategies in patient care.

Question 50

Scenario: A patient with a new colostomy expresses fear and refuses to look at the stoma. What is the nurse's best response?

Accepted Answer

Answer reason: u." This uses therapeutic communication to explore the patient’s fear and feelings, which is the priority before teaching or task demands. A new ostomy can provoke anxiety, altered body image, and grief; inviting discussion helps build trust and readiness to participate in care. The other responses minimize concerns, shift responsibility to family, or push education before addressing emotional barriers, which can increase resistance.
Category reason: This question tests the nurse’s communication technique to address anxiety and promote coping with a new health alteration, which fits Psychosocial Integrity—Therapeutic Communication.

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Assertive communication means

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First phase of interpersonal relationship is known as?

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Cloze: A nurse is using therapeutic communication with a patient who says, "I'm worthless." The best response is?

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A nurse is interviewing an adolescent client who has a history of physical aggression due to anger management issues. Which of the following is an appropriate question by the nurse?

Non-verbal communication-

During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the coming up the next day. Which intervention is most important for the RN to implement during the admission process?

A client doesn't make eye contact with the nurse during an interview. The nurse suspects that the client's behavior has a cultural basis. What should the nurse do first?

Which of the following interventions will likely ensure compliance of Mariah?

Scenario: A patient with a new colostomy expresses fear and refuses to look at the stoma. What is the nurse's best response?

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