Saunder’s NCLEX Questions - Foundations of Psychiatric Mental Health Nursing
1. Unresolved feelings related to loss may be most likely recognized during which phase of the therapeutic nurseclient relationship?
a. Orientation
b. Working
c. Termination
d. Trusting
2. A client with a diagnosis of major depression who attempted suicide says to the nurse, “I should have died. I’ve
always been a failure. Nothing ever goes right for me.” The most therapeutic response to the client is:
a. “I don’t see you as a failure.”
b. “Feeling like this is all part of being ill.”
c. “You’ve been feeling like a failure for a while?”
d. “You have everything to live for.”
3. A community health nurse visits a client at home. The client states, “I haven’t slept at all the last couple of
nights.” Which response by the nurse illustrates the most therapeutic communication technique for this client?
a. “Go on…”
b. “Sleeping?”
c. “The last couple of nights?”
d. “You’re having difficulty sleeping?”
4. A nurse is performing an admission assessment on a client and is attempting to obtain subjective data about the
client’s sexual and reproductive status. The client states, “I don’t want to discuss this; it’s private and personal.”
Which statement, if made by the nurse, indicates that the nurse is therapeutic?
a. “I hate being asked these sorts of questions too.”
b. “I am a professional nurse and as such I’ll have you know that all information is kept confidential.”
c. “I know that some of these questions are difficult for you but, as a professional nurse, I must legally
respect your confidentiality.”
d. “This is difficult for you to speak about, but I am trying to perform a complete assessment and I need
this information.”
5. A nurse is caring for a Native American client who says, “I don’t want you to touch me. I’ll take care of myself!”
Which nursing response is most therapeutic?
a. “Ok. If that’s what you want. I’ll just leave this cup for you to collect your urine in. After breakfast, I will
take more blood from you.”
b. “If you didn’t want our care, why did you come here?”
c. “Why are you being so difficult? I only want to help you.”
d. “It sounds as though you want to take care of yourself. Let’s work together so you can do things for
yourself.”
6. A client admitted to the mental health unit is experiencing Altered Thought Processes. The client believes that
the food is being poisoned. Which communication technique does the nurse plan to use to encourage the client
to express feelings?
a. Using open-ended questions and silence
b. Offering opinions about the necessity of adequate nutrition
c. Identifying the reasons that the client may not want to eat
d. Focusing on the self-disclosure about food preferences.
7. A nurse is working with a client who has sought counseling after trying to rescue a neighbor involved in a house
fire. In spite of the client’s efforts, the neighbor died. Which action does the nurse engage in with the client
during the working phase of the nurse-client relationship?
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a. Exploring the client’s potential for self-harm
b. Exploring the client’s ability to function
c. Inquiring about the client’s perception or appraisal of the neighbor’s death.
d. Inquiring about and examining the client’s feelings that may block adaptive coping.
A client who has just been sexually assaulted is very quiet and calm. The nurse analyzes this behavior as
indicative of which defense mechanism?
a. Denial
b. Projection
c. Rationalization
d. Intellectualization
A nurse completes the initial assessment of a client admitted to the mental health unit. The nurse analyzes the
data obtained on assessment and determines that which of the following presents a priority concern?
a. The presence of bruises on the client’s body
b. The client’s report of not eating or sleeping
c. The client’s report of suicidal thoughts
d. The significant other’s disapproving of the treatment
Laboratory work is prescribed for a client who has been experiencing delusions. When the nurse approaches the
client to obtain a specimen of the client’s blood, the client begins to shout, “You’re all vampires. Let me out of
here!” The most appropriate nursing response is which of the following?
a. “I am not going to hurt you. I am going to help you!”
b. “What makes you think that I am a vampire?”
c. “I’ll leave and come back later for your blood.”
d. “It must be fearful to think others want to hurt you.”
An inebriated client is brought to the ER department by the local police. The client is told that the physician will
be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by
the physician immediately. The most appropriate nursing intervention is which of the following?
a. Attempt to talk with the client to deescalate behavior
b. Watch the behavior escalate before intervening
c. Inform the client that he or she will be asked to leave if the behavior continues
d. Offer to take the client to an examination room until he or she can be treated
A client is admitted to a mental health unit for treatment of psychotic behavior. The client is at the locked exit
door and is shouting, “Let me out. There’s nothing wrong with me. I don’t belong here.” The nurse analyzes this
behavior as:
a. Projection
b. Denial
c. Regression
d. Rationalization
A home health nurse is talking to the spouse of a client taking an antidepressant. The spouse says, “Now that my
husband is responding to the antidepressant, the suicidal risk is over and you can stop making these home
visits.” After analyzing this statement, which of the following is the most appropriate nursing response?
a. “I agree with you. Clients who want to kill themselves are only suicidal for a limited time. No one can
feel self-destructive forever.”
b. “I need to continue with my visits. Your comment reflects a lack of knowledge that this disease runs in
families.”
c. “I agree with you. The suicidal threats were really attention seeking. Continuing to visit would reinforce
your husband’s use of manipulation”.
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d. “I need to continue with my visits. Most suicides occur within 3 months after improvement begins
because the client now has the energy to carry out the suicidal intentions.”
A supervisor reprimands the nurse in charge of a nursing unit because the charge nurse has not adhered to the
unit budget. Later that afternoon, the charge nurse accuses the nursing staff of wasting supplies. This behavior is
an example of:
a. Denial
b. Repression
c. Suppression
d. Displacement
A client says to the nurse, “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry
when they carry on like this! After all, I’m the one who’s dying.” The most therapeutic response by the nurse is:
a. “You’re feeling angry that your family continues to hope for you to be cured?”
b. “I think we should talk more about your anger with your family.”
c. “Well, it sounds like you’re being pretty pessimistic. After all, years ago people died of pneumonia.”
d. “Have you shared your feelings with your family?”
A nurse employed in a mental health unit is assigned to care for a client admitted to the unit 2 days ago. On
review of the client’s record, the nurse notes that the admission was a voluntary admission. Based on this type
of admission, the nurse anticipates which of the following?
a. The client will be very resistant to treatment measures
b. The client’s family will be very resistant to treatment measures
c. The client will be angry and will refuse care
d. The client will participate in the planning of the care and treatment plan.
A nurse enters a client’s room and the client is demanding release from the hospital. The nurse reviews the
client’s record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that
the admission was voluntary. Which of the following actions will the nurse take?
a. Tell the client that discharge is not possible at this time
b. Call the client’s family
c. Contact the physician
d. Persuade the client to stay a few more days
A client is admitted to the mental health unit. On client is admitted by involuntary status. Based on this type of
admission, the nurse would most likely expect that the client:
a. Presents a harm to self
b. Requested the admission
c. Consented to the admission
d. Provided written application to the facility for admission
A nurse is caring for a client who is schedule for electroconvulsive therapy (ECT). The nurse notes that an
informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the
admission was an involuntary hospitalization. Based on this information, the nurse determines:
a. The an informed consent does not need to be obtained
b. That an informed consent should be obtained from the family
c. That an informed consent needs to be obtained from the client
d. That the physician will obtain the informed consent
After a group therapy session, a client approaches a nurse and verbalizes a need for seclusion because of
uncontrollable feelings. The most appropriate nursing action would be to:
a. Inform the client that seclusion has not been prescribed
b. Obtain an informed consent
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c. Call the client’s family
d. Place the client in seclusion immediately
A nurse is providing care to client admitted to the hospital with a diagnosis of acute anxiety disorder. The nurse
is conversing with the client. The client says to the nurse “I have a secret that I want to tell you. You won’t tell
anyone about it, will you?” The most appropriate nursing response is which of the following?
a. “No, I won’t tell anyone.”
b. “I cannot promise to keep a secret.”
c. “If you tell me the secret, I will tell it to your doctor.”
d. “If you tell me the secret, I will need to document it in your record.”
A nurse employed in the mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says
to the nurse, “How is Carol doing? She is my best friend and is seen at your clinic every week.” The most
appropriate nursing response is which of the following?
a. “I’m not supposed to discuss this, but since you are my neighbor, I can tell you that she is doing great!”
b. “I’m not supposed to discuss this, but since you are my neighbor, I can tell you that she really has some
problems!”
c. “If you want to know about Carol, you need to ask her yourself.”
d. “I cannot discuss any client situation with you.”
A client was involuntarily admitted to the mental health unit because of episodes of extremely violent behavior.
The client is demanding to be discharged from the hospital. The nurse does not allow the client to leave. Which
of the following represent the legal ramifications associated with the nurse’s behavior?
a. The nurse will be charged with imprisonment
b. The nurse will be charged with assault
c. The nurse will be charged with slander
d. No charge will be made against the nurse because the nurse’s actions are reasonable.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to
implement which nursing task that is most appropriate for this phase?
a. Identifying expected outcomes
b. Planning short-term goals
c. Making appropriate referrals
d. Developing realistic solutions
During the termination phase of the nurse-client relationship, the clinic nurse observes that the client
continuously demonstrates bursts of anger. The most appropriate interpretation of the behavior is that the
client:
a. Requires further treatment and is not ready to be discharged
b. Is displaying typical behaviors that can occur during termination
c. Needs to be admitted to the hospital
d. Needs to be referred to the psychiatrist as soon as possible
Answers
1. C; Rationale: In the termination phase, the relationship comes to a close. Ending treatment can sometimes be
traumatic for clients who have come to value the relationship and the help. Since loss is an issue, any unresolved
feelings related to loss may resurface during this phase.
2. C; Rationale: Responding to the feelings expressed by a client is effective therapeutic communication technique.
3. D; Rationale: The most therapeutic nursing communication technique is restatement.
4. C; Rationale: C is the only option that identifies a therapeutic response.
5. D; Rationale: Native Americans view touch very differently from other Americans. The most therapeutic
response is the one that reflects the client’s feelings and empowers the client by offering self control over one’s
own care.
6. A; Rationale: Open-ended questions and silence are strategies used to encourage clients to discuss their
problem.
7. D; Rationale: The client must first deal with feelings and negative responses before being able to work through
the meaning of the crisis.
8. A; Rationale: Denial is an adaptive and protective reaction and may be response by a victim of sexual abuse.
9. C; Rationale: The client’s thoughts are extremely important when verbalized. A client’s report of suicidal
thoughts is highest priority.
10. D; Rationale: D helps the client to focus on the emotion underlying the delusion but does not argue with it.
11. D; Rationale: Safety of the client, other clients, and staff is of prime concern.
12. B; Rationale: Denial is refusal to admit to a painful reality, which is treated as if it does not exist.
13. D; Rationale: Most suicides occur within 3 months after the beginning of the improvement, when the client has
the energy to carry out the suicidal intentions.
14. D; Rationale: Ego defense mechanisms are operations outside a person’s awareness that the ego calls into play
to protect against anxiety.
15. A; Rationale: restating is the therapeutic communication technique.
16. D; Rationale: If the client seeks voluntary admission, the most likely expectation is that he client will participate.
17. C; Rationale: Voluntary clients have the right to demand and obtain release.
18. A; Rationale: Involuntary admission is necessary when a person is a danger to self or others or is in need of
psychiatric treatment.
19. C; Rationale: Clients who are involuntarily admitted do not lose their right to informed consent. Clients must be
considered legally competent until they have been declared incompetent through legal proceeding.
20. B; Rationale: Federal laws require the consent of the client, unless an emergency situation exists in which an
immediate risk to the client or others can be documented.
21. B; Rationale: The nurse should never promise to keep a secret. Nurse needs to be honest.
22. D; Rationale: A nurse is required to maintain confidentiality about the client and his or her care.
23. D; Rationale: False imprisonment is an act with the intent to confine a person to a specific area.
24. C; Rationale: Tasks of termination phase include evaluating client performance, evaluating achievement of
expected outcomes, evaluating future needs, making appropriate referrals, and dealing with the common
behaviors associated with termination.
25. B; Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of
regressive behaviors that can be disturbing to the nurse.