Violence Risk Assessment
A 26-year-old male with bipolar disorder is pacing, clenching his fists, and speaking loudly. Which finding is the strongest predictor of violent behavior?
A. Male gender
B. Substance use history
C. Diagnosis of bipolar disorder
D. Previous acts of violence
Correct Answer: D
Rationale: A history of violence is the single most reliable predictor of future violent behavior and outweighs demographic or diagnostic factors.
Which nursing approach is most effective when interacting with an escalating patient?
A. Firm authoritative commands
B. Lengthy explanations
C. Calm voice with short sentences
D. Confronting the patient’s behavior
Correct Answer: C
Rationale: Calm tone and simple language reduce cognitive overload and help prevent escalation.
A patient receives IM haloperidol for acute agitation. Which adverse effect should the nurse monitor?
A. Hyperglycemia
B. Extrapyramidal symptoms
C. Serotonin syndrome
D. Hypertensive crisis
Correct Answer: B
Rationale: Typical antipsychotics commonly cause EPS.
A patient states, “I wish I wouldn’t wake up tomorrow.” How should this be interpreted?
A. Normal stress response
B. Passive suicidal ideation
C. Attention-seeking behavior
D. Low risk statement
Correct Answer: B
Rationale: Passive death wishes indicate suicidal ideation and must be taken seriously.
Which item poses the greatest ligature risk?
A. Bedside table
B. IV tubing
C. Plastic cup
D. Pillow
Correct Answer: B
Rationale: Flexible cords and tubing present high strangulation risk.
ligature = a thing used for tying or binding something tightly
A patient states, “They’re going to regret how they treated me.” What is the priority nursing assessment?
A. Assess mood and affect
B. Ask if the patient has a specific plan
C. Notify security immediately
D. Offer PRN medication
Correct Answer: B
Rationale: NCLEX prioritizes assessing intent, plan, and means before interventions or escalation.
Which action should the nurse avoid during verbal de-escalation?
A. Maintaining personal space
B. Avoiding eye contact entirely
C. Remaining calm
D. Using open-ended statements
Correct Answer: B
Rationale: Complete avoidance of eye contact may be perceived as dismissive or threatening.
A patient taking risperidone develops lip smacking and tongue movements. Which medication is indicated?
A. Lorazepam
B. Benztropine
C. Lithium
D. Valproate
Correct Answer: B
Rationale: Benztropine treats antipsychotic-induced movement disorders.
Which suicide method is considered high lethality?
A. Cutting wrists
B. Medication overdose
C. Firearms
D. Superficial burns
Correct Answer: C
Rationale: Firearms have the highest fatality rate among suicide methods.
A patient avoids eye contact, has inconsistent stories, and lacks identification. What is the nurse’s priority action?
A. Notify law enforcement
B. Question the companion
C. Screen the patient privately
D. Discharge the patient
Correct Answer: C
Rationale: Private, trauma-informed screening is the priority nursing action.
A patient with a traumatic brain injury becomes aggressive when overstimulated. Which brain area dysfunction most contributes to this behavior?
A. Cerebellum
B. Occipital lobe
C. Prefrontal cortex
D. Brainstem
Correct Answer: C
Rationale: The prefrontal cortex regulates judgment and impulse control. Damage leads to impulsive and aggressive responses.
A patient placed in restraints is now calm and following commands. What is the next nursing action?
A. Remove restraints immediately
B. Leave the patient alone
C. Begin gradual reintegration with monitoring
D. Discontinue documentation
Correct Answer: C
Rationale: Reintegration must be gradual and closely monitored to maintain safety.
Which food choice should a patient taking an MAOI avoid?
A. Fresh fruit
B. Grilled chicken
C. Aged cheese
D. Steamed vegetables
Correct Answer: C
Rationale: Tyramine-containing foods can cause a hypertensive crisis when combined with MAOIs.
Adolescents are at increased suicide risk primarily due to:
A. Hormonal imbalance
B. Poor moral reasoning
C. Immature prefrontal cortex
D. Lack of empathy
Correct Answer: C
Rationale: An underdeveloped prefrontal cortex limits impulse control and decision-making.
A patient experiencing auditory hallucinations says,
“The voices are telling me I’m worthless.”
What is the nurse’s best response?
A. “Those voices aren’t real.”
B. “What are the voices saying to you?”
C. “You shouldn’t listen to them.”
D. “Try to distract yourself when you hear them.”
Correct Answer: B
Rationale:
A: Confronts the hallucination and can increase defensiveness.
B: Therapeutic. Acknowledges the experience without reinforcing the hallucination.
C: Dismissive and offers no emotional support.
D: Premature problem-solving without assessment.
Low serotonin levels are most closely associated with which behavior?
A. Withdrawal and apathy
B. Impulsive aggression
C. Sedation
D. Hallucinations
Correct Answer: B
Rationale: Low serotonin reduces inhibitory control, increasing impulsivity and aggression.
Which milieu characteristic most increases the risk of violent behavior?
A. Structured routines
B. Adequate staffing
C. Overcrowding
D. Clear limit setting
Correct Answer: C
Rationale: Overcrowding increases stress, frustration, and loss of emotional control.
Which lithium level requires immediate provider notification?
A. 0.8 mmol/L
B. 1.0 mmol/L
C. 1.3 mmol/L
D. 0.7 mmol/L
Correct Answer: C
Rationale: Therapeutic range is 0.6–1.2 mmol/L. Levels above this increase toxicity risk.
Which SAFE-T step guides the level of nursing intervention?
A. Identifying risk factors
B. Identifying protective factors
C. Determining risk level
D. Documentation
Correct Answer: C
Rationale: Risk level determines monitoring intensity and safety interventions.
A patient says,
“I’m being punished for everything I’ve done wrong.”
What is the nurse’s best response?
A. “What makes you think you’re being punished?”
B. “You’re not being punished.”
C. “That sounds like a very heavy burden to carry.”
D. “Everyone makes mistakes.”
Correct Answer: C
Rationale:
A: Sounds like a “why” question and may feel interrogative.
B: Directly challenges the belief without exploring feelings.
C: Therapeutic. Empathizes with emotional distress without reinforcing delusions.
D: Minimizes the patient’s emotional experience.
A patient with anxiety repeatedly asks,
“Am I going to be okay?”
Which response is most therapeutic?
A. “Yes, everything will be fine.”
B. “I don’t know, but we’re doing our best.”
C. “What specifically are you worried about right now?”
D. “Try not to think about it.”
Correct Answer: C
Rationale:
A: False reassurance and unrealistic.
B: Honest but increases anxiety by emphasizing uncertainty.
C: Therapeutic. Focuses the patient on specific concerns and promotes expression.
D: Minimizes anxiety and blocks communication.
A patient angrily states,
“No one here cares if I live or die!”
What is the nurse’s most appropriate response?
A. “That’s not true. We care about you.”
B. “You sound very angry right now.”
C. “You shouldn’t say things like that.”
D. “Do you want to hurt yourself?”
Correct Answer: B
Rationale:
A: Defensive reassurance that invalidates feelings.
B: Therapeutic. Reflects emotion and acknowledges the patient’s experience.
C: Judgmental and shuts down communication.
D: Important assessment, but emotional validation comes first unless imminent danger is expressed.
A patient begins crying during an interview and becomes silent.
What is the nurse’s most therapeutic action?
A. Offer advice to stop the crying
B. Change the subject
C. Sit quietly and remain present
D. Ask multiple follow-up questions
Correct Answer: C
Rationale:
A: Advice-giving is nontherapeutic and dismissive.
B: Avoids emotional processing.
C: Therapeutic. Silence conveys acceptance and allows emotional expression.
D: Overwhelming and intrusive during emotional distress.
A patient diagnosed with major depressive disorder states,
“I feel like everything I do is wrong.”
Which nurse response is most therapeutic?
A. “That’s not true. You do many things well.”
B. “Why do you think you feel that way?”
C. “Tell me more about what makes you feel this way.”
D. “Everyone feels that way sometimes.”
Correct Answer: C
Rationale:
A: Nontherapeutic. This minimizes the patient’s feelings and offers false reassurance.
B: “Why” questions can sound accusatory and put the patient on the defensive.
C: Therapeutic. Encourages expression and exploration of feelings without judgment.
D: Minimizes and normalizes distress inappropriately.
A patient who recently attempted suicide says,
“I don’t want to talk about it.”
What is the nurse’s best response?
A. “You have to talk about it so we can help you.”
B. “That’s fine. Let me know when you’re ready.”
C. “It’s important to discuss this now.”
D. “Why don’t you want to talk about it?”
Correct Answer: B
Rationale:
A: Coercive and violates patient autonomy.
B: Therapeutic. Respects boundaries while keeping the door open.
C: Authoritative and increases resistance.
D: “Why” questions may feel accusatory.