Module 5
A patient on an inpatient psychiatric unit begins pacing, clenching fists, and muttering angrily after receiving upsetting news. What is the most appropriate nursing intervention?
A. Tell the patient to stop pacing and sit down.
B. Move the patient to a quiet area and use a calm voice.
C. Place the patient in seclusion immediately.
D. Call security for restraint support.
Correct Answer: B
Rationale: In the triggering phase, the nurse should use calm, empathetic communication and reduce environmental stimuli to help the patient regain control
A nurse is assessing a child diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). Which nursing intervention is the highest priority?
A. Encourage the child to engage in creative play
B. Provide a structured environment with clear limits
C. Allow the child to complete homework independently
D. Offer frequent, unplanned activities to prevent boredom
Correct Answer: B
Rationale: Children with ADHD benefit from a structured, predictable environment and consistent rules to help manage impulsivity and inattention.
Which patient on an inpatient psychiatric unit is at the highest risk for exhibiting violent behavior?
A. A patient with major depression who isolates in their room
B. A patient with paranoid delusions and loud, pressured speech
C. A patient with generalized anxiety disorder who frequently seeks reassurance
D. A patient with obsessive-compulsive disorder performing handwashing rituals
Correct Answer: B
Rationale: Paranoid delusions and agitation increase the risk for violence. Suspicious or psychotic patients may misinterpret others’ actions as threatening
A nurse notes that a 10-year-old refuses to attend school, clinging to a parent at drop-off. This behavior most likely indicates:
A. Social anxiety disorder
B. Separation anxiety disorder
C. Panic disorder
D. Generalized anxiety disorder
Correct Answer: B
Rationale: Excessive distress when separated from caregivers is characteristic of separation anxiety disorder, common in childhood.
A patient in a domestic violence shelter tells the nurse, “I feel like it’s my fault—he always apologizes afterward, and I just want to believe him.” Which nursing response is most therapeutic?
A. “You should focus on leaving him immediately.”
B. “It’s common for victims to blame themselves; you are not responsible for his actions.”
C. “If you forgive him, it may help you both move on.”
D. “You should stay quiet until he changes.”
Correct Answer: B
Rationale: The nurse must validate the survivor’s feelings, reinforce that abuse is never justified, and promote empowerment without judgment
During the escalation phase, a patient begins yelling and threatening staff. Which action is most appropriate?
A. Administer PRN oral antianxiety medication if accepted.
B. Use physical restraint immediately.
C. Ignore the behavior until the patient calms down.
D. Leave the patient alone to avoid confrontation.
Correct Answer: A
Rationale: In the escalation phase, nurses should offer PRN oral medications (e.g., lorazepam or haloperidol) early and use de-escalation strategies to prevent crisis
When caring for a child with Autism Spectrum Disorder (ASD), which nursing approach is most appropriate?
A. Encourage physical touch to establish trust
B. Provide large group therapy sessions for socialization
C. Maintain a consistent daily routine with minimal stimuli
D. Encourage open-ended questions to improve language skills
Correct Answer: C
Rationale: Children with ASD respond best to structured, low-stimulus environments; changes or excessive stimulation may cause distress.
After a violent outburst, the patient calms down and appears withdrawn. What is the most therapeutic nursing action during this recovery phase?
A. Resume group activities immediately to promote normalcy
B. Encourage the patient to discuss what triggered the episode
C. Avoid discussing the incident to prevent further agitation
D. Continue close observation but limit verbal interaction
Correct Answer: B
Rationale: During recovery, the nurse helps the patient explore triggers, learn coping skills, and process the event safely
A nurse caring for a hospitalized preschooler uses play therapy. Which action best demonstrates understanding of therapeutic play principles?
A. Allowing the child to act out feelings using dolls
B. Focusing play only on educational tasks
C. Discouraging expression of negative emotions
D. Providing structured games with rigid rules
Correct Answer: A
Rationale: Play therapy helps children express emotions safely and is particularly useful for those unable to verbalize distress.
A nurse caring for a survivor of sexual assault recognizes that the patient is beginning to talk about the event and express anger. The nurse identifies this as which stage of recovery?
A. Impact stage
B. Recoil stage
C. Reorganization stage
D. Resolution stage
Correct Answer: B
Rationale: The recoil stage occurs weeks to months after the trauma, when the survivor begins processing emotions and discussing the experience with others
A patient begins swinging at another patient and yelling threats. What should be the nurse’s first action?
A. Attempt verbal redirection.
B. Move other patients to safety and initiate emergency protocols.
C. Document the behavior.
D. Leave the patient alone to avoid triggering further aggression.
Correct Answer: B
Rationale: During the crisis phase, safety is the top priority. Nurses must protect others and initiate emergency seclusion or restraint protocols if necessary
A 9-year-old with ODD frequently argues with teachers and refuses to follow directions. Which nursing goal is most appropriate?
A. The child will comply with all instructions immediately
B. The child will express frustration using appropriate language
C. The child will avoid all conflicts with authority figures
D. The child will remain isolated to prevent arguments
Correct Answer: B
Rationale: For ODD, goals focus on expressing anger and frustration in healthy ways rather than eliminating defiance entirely.
Following an episode of patient aggression, which documentation by the nurse is most appropriate?
A. “Patient became violent and required restraint.”
B. “Restraints applied after patient punched wall; PRN haloperidol 5 mg IM administered; patient calm within 15 minutes; safety maintained.”
C. “Patient out of control—staff intervened as needed.”
D. “Patient required medication for behavior.”
Correct Answer: B
Rationale: Documentation must include objective behavior, interventions, medications, timing, and patient response. This ensures legal and safety accountability
In planning care for a child with a mental health disorder, which nursing action is most critical to long-term success?
A. Emphasize medication adherence only
B. Provide therapy sessions for the child alone
C. Include the family in education and treatment planning
D. Focus interventions solely on school behavior
Correct Answer: C
Rationale: Family participation promotes consistency across environments and improves treatment outcomes for pediatric mental health disorders.
A 6-year-old child presents with multiple bruises on the thighs and states, “Daddy got mad and hit me.” Which nursing action is most appropriate?
A. Report the suspected abuse to child protective services.
B. Ask the parents for clarification before taking further action.
C. Document findings and continue observation.
D. Ask the child to tell their teacher instead.
Correct Answer: A
Rationale: Nurses are mandated reporters. Any suspicion of abuse must be reported to authorities immediately—proof is not required
A patient expresses suicidal thoughts and states, “I just can’t go on anymore.” What is the nurse’s best response?
A. “You have so much to live for.”
B. “Have you thought about how you might harm yourself?”
C. “You should think of your family before doing anything.”
D. “Let’s distract you by talking about something positive.”
Correct Answer: B
Rationale: The nurse must assess suicidal ideation directly and nonjudgmentally by asking about plan, method, and intent
Which behavior in a child diagnosed with Conduct Disorder requires immediate intervention by the nurse?
A. Defacing school property
B. Skipping classes
C. Aggression toward animals or people
D. Ignoring household rules
Correct Answer: C
Rationale: Aggressive acts that harm others or animals indicate severe behavioral disturbance and pose immediate safety risks.
Which nursing intervention demonstrates primary prevention of suicide?
A. Conducting a post-suicide debriefing with staff
B. Monitoring a patient after a suicide attempt
C. Teaching coping strategies in a stress management group
D. Completing a lethality assessment
Correct Answer: C
Rationale: Primary prevention aims to reduce suicide risk before it occurs by promoting mental wellness and coping strategies
A nurse teaches parents about methylphenidate (Ritalin). Which statement by the parent indicates a need for further teaching?
A. “We will give the medication after breakfast each day.”
B. “We should monitor our child’s weight and appetite.”
C. “We will avoid giving the dose after 4 p.m.”
D. “We can stop the medication during weekends and holidays.”
Correct Answer: D
Rationale: Abruptly stopping stimulant medication without provider guidance can cause rebound symptoms; dosing schedules must be consistent.
An older adult reports poor appetite, fatigue, and insomnia. The nurse suspects depression rather than normal aging because the patient also expresses:
A. A desire to spend more time with family
B. Feelings of hopelessness and guilt
C. Frustration with physical limitations
D. Difficulty remembering names
Correct Answer: B
Rationale: Depression in older adults often presents with hopelessness, guilt, and somatic symptoms rather than sadness alone
A psychiatric nurse reports nightmares, anxiety, and feelings of guilt after being assaulted by a patient. Which concept best describes this response?
A. Compassion satisfaction
B. Secondary traumatization
C. Moral resilience
D. Countertransference
Correct Answer: B
Rationale: Secondary traumatization occurs when nurses experience psychological distress after exposure to patients’ trauma or direct violence, leading to symptoms similar to PTSD
A school-aged child diagnosed with depression is withdrawn and expresses feelings of worthlessness. Which nursing intervention is most therapeutic?
A. Encourage the child to make new friends
B. Challenge negative self-statements directly
C. Spend short, frequent periods of time with the child
D. Avoid discussing the child’s feelings to prevent crying
Correct Answer: C
Rationale: Brief, consistent contact fosters trust and security for depressed children who often struggle with attachment and self-worth.
A patient is pacing and shouting loudly on the unit but is not physically aggressive. Which intervention aligns with the principle of least restrictive care?
A. Administering IM medication immediately
B. Placing the patient in seclusion
C. Using verbal de-escalation and offering space to calm down
D. Applying four-point restraints
Correct Answer: C
Rationale: Verbal de-escalation and allowing personal space should always be attempted before seclusion or restraint, which are more restrictive interventions
An adolescent patient says, “My family would be better off without me.” What is the nurse’s priority response?
A. “You shouldn’t feel that way.”
B. “Are you thinking about hurting yourself?”
C. “Let’s focus on positive thoughts.”
D. “Would you like to talk to your parents?”
Correct Answer: B
Rationale: Directly assessing suicidal thoughts and intent is essential for safety; this question opens communication without judgment.
The nurse reviews new medication orders for an 82-year-old patient starting an antidepressant. Which principle of geriatric psychopharmacology should guide care?
A. Start high, then taper quickly
B. Avoid monitoring blood levels
C. Start low, go slow
D. Double the initial dose if ineffective
Correct Answer: C
Rationale: Due to age-related changes in metabolism and renal clearance, the “start low, go slow” rule minimizes adverse reactions in older adults