SAUNDERS MENTAL HEALTH EXAM 2026/2027
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[Section 1: Psychiatric Foundations & Legal/Ethical Issues (Q1-25)]
Question 1 A psychiatric nurse is caring for a client who states, "I am going to leave this
hospital right now against medical advice." The client is currently on an involuntary
hold for danger to self. What is the nurse's priority action?
A. Immediately notify the healthcare provider and initiate one-to-one observation
B. Allow the client to leave and document the incident in the medical record
C. Restrain the client to prevent elopement and ensure safety
D. Call security to block all exits and notify law enforcement
Correct Answer: A A. Immediately notify the healthcare provider and initiate one-to-
one observation [CORRECT] Rationale: The nurse must notify the provider of the
client's intent to leave AMA while maintaining safety through close observation;
restraints require provider orders and least restrictive measures must be attempted
first. Options B, C, and D violate legal protocols or use excessive force without proper
authorization.
Question 2 Which of the following actions by a nurse demonstrates a violation of the
client's right to confidentiality under HIPAA?
A. Discussing a client's diagnosis with the interdisciplinary treatment team in a private
conference room
,B. Sharing a client's psychiatric history with the client's spouse without written consent
C. Reporting suspected child abuse to the appropriate state authorities
D. Documenting a client's suicidal ideation in the electronic medical record
Correct Answer: B B. Sharing a client's psychiatric history with the client's spouse
without written consent [CORRECT] Rationale: HIPAA requires written client consent
before disclosing protected health information to family members; exceptions include
mandatory reporting (C) and treatment team communication (A). Option D is standard
documentation practice.
Question 3 A client with schizophrenia refuses to take prescribed antipsychotic
medication, stating, "These pills are poison." The client is competent to make medical
decisions. What is the nurse's most appropriate response?
A. "You must take this medication; it is court-ordered."
B. "Let me explain how this medication helps control your symptoms."
C. "I understand you have concerns. Can you tell me more about why you feel this way?"
D. "If you don't take it, I will have to give you an injection instead."
Correct Answer: C C. "I understand you have concerns. Can you tell me more about
why you feel this way?" [CORRECT] Rationale: A competent client has the right to
refuse medication; the therapeutic nurse-client relationship requires exploring
concerns through open-ended communication. Options A, B, and D are coercive,
paternalistic, or threatening.
Question 4 The nurse is reviewing the legal requirements for seclusion and restraint.
Which statement accurately reflects current standards?
A. A provider's order must be obtained within 1 hour of application
B. Continuous visual monitoring is required every 30 minutes
C. The client must be released immediately upon request
D. A face-to-face evaluation by a provider is required within 4 hours for adults
,Correct Answer: D D. A face-to-face evaluation by a provider is required within 4 hours
for adults [CORRECT] Rationale: CMS regulations require a face-to-face evaluation
within 1 hour for children/adolescents and 4 hours for adults; orders must be obtained
before application (not within 1 hour after), and continuous monitoring (not every 30
minutes) is required. Option C is incorrect as release depends on safety assessment.
Question 5 A client tells the nurse, "I have a plan to hurt my neighbor because he is
spying on me." The nurse understands that this statement requires which mandatory
action?
A. Maintain confidentiality as this is part of the therapeutic relationship
B. Assess the client's perception of reality before taking action
C. Warn the intended victim and notify law enforcement per duty to warn statutes
D. Document the statement and continue routine monitoring
Correct Answer: C C. Warn the intended victim and notify law enforcement per duty to
warn statutes [CORRECT] Rationale: The Tarasoff duty to warn mandates breaking
confidentiality when a client presents a credible threat to a specific individual. Options
A and D place the potential victim at risk, while B delays necessary protective action.
Question 6 A psychiatric unit is implementing trauma-informed care principles. Which
nursing action best aligns with this framework?
A. Establishing strict routines to provide predictability for all clients
B. Asking clients for permission before entering personal space or touching
C. Limiting client choices to reduce anxiety and confusion
D. Using seclusion as a first-line intervention for agitated behavior
Correct Answer: B B. Asking clients for permission before entering personal space or
touching [CORRECT] Rationale: Trauma-informed care emphasizes safety,
trustworthiness, choice, collaboration, and empowerment; asking permission respects
autonomy and reduces re-traumatization. Options A and C limit autonomy, while D
contradicts trauma-informed principles.
, Question 7 Which of the following is the nurse's priority responsibility when obtaining
informed consent for electroconvulsive therapy (ECT)?
A. Explain the procedure, risks, benefits, and alternatives to the client
B. Obtain the client's signature on the consent form
C. Ensure a family member is present to witness the consent
D. Verify that the client has tried at least three antidepressant medications first
Correct Answer: A A. Explain the procedure, risks, benefits, and alternatives to the
client [CORRECT] Rationale: Informed consent requires ensuring the client
understands the procedure, risks, benefits, and alternatives; the nurse verifies
understanding but the provider obtains consent. Option B alone is insufficient without
comprehension, C is not required, and D describes treatment resistance criteria, not
consent requirements.
Question 8 A client with bipolar disorder is admitted involuntarily after manic
behavior endangered others. The nurse understands that involuntary commitment
criteria include which elements?
A. The client must agree to voluntary admission within 24 hours
B. The client presents a danger to self or others or is gravely disabled
C. The client must have a diagnosed severe mental illness
D. The client's family must request the involuntary admission
Correct Answer: B B. The client presents a danger to self or others or is gravely
disabled [CORRECT] Rationale: Involuntary commitment requires imminent danger to
self/others or inability to care for basic needs (grave disability); a specific diagnosis (C)
or family request (D) alone is insufficient, and option A describes voluntary conversion,
not commitment criteria.
| Questions & Answers | Already Graded A |
Complete NCLEX Review | Pass Guaranteed -
A+ Graded
[Section 1: Psychiatric Foundations & Legal/Ethical Issues (Q1-25)]
Question 1 A psychiatric nurse is caring for a client who states, "I am going to leave this
hospital right now against medical advice." The client is currently on an involuntary
hold for danger to self. What is the nurse's priority action?
A. Immediately notify the healthcare provider and initiate one-to-one observation
B. Allow the client to leave and document the incident in the medical record
C. Restrain the client to prevent elopement and ensure safety
D. Call security to block all exits and notify law enforcement
Correct Answer: A A. Immediately notify the healthcare provider and initiate one-to-
one observation [CORRECT] Rationale: The nurse must notify the provider of the
client's intent to leave AMA while maintaining safety through close observation;
restraints require provider orders and least restrictive measures must be attempted
first. Options B, C, and D violate legal protocols or use excessive force without proper
authorization.
Question 2 Which of the following actions by a nurse demonstrates a violation of the
client's right to confidentiality under HIPAA?
A. Discussing a client's diagnosis with the interdisciplinary treatment team in a private
conference room
,B. Sharing a client's psychiatric history with the client's spouse without written consent
C. Reporting suspected child abuse to the appropriate state authorities
D. Documenting a client's suicidal ideation in the electronic medical record
Correct Answer: B B. Sharing a client's psychiatric history with the client's spouse
without written consent [CORRECT] Rationale: HIPAA requires written client consent
before disclosing protected health information to family members; exceptions include
mandatory reporting (C) and treatment team communication (A). Option D is standard
documentation practice.
Question 3 A client with schizophrenia refuses to take prescribed antipsychotic
medication, stating, "These pills are poison." The client is competent to make medical
decisions. What is the nurse's most appropriate response?
A. "You must take this medication; it is court-ordered."
B. "Let me explain how this medication helps control your symptoms."
C. "I understand you have concerns. Can you tell me more about why you feel this way?"
D. "If you don't take it, I will have to give you an injection instead."
Correct Answer: C C. "I understand you have concerns. Can you tell me more about
why you feel this way?" [CORRECT] Rationale: A competent client has the right to
refuse medication; the therapeutic nurse-client relationship requires exploring
concerns through open-ended communication. Options A, B, and D are coercive,
paternalistic, or threatening.
Question 4 The nurse is reviewing the legal requirements for seclusion and restraint.
Which statement accurately reflects current standards?
A. A provider's order must be obtained within 1 hour of application
B. Continuous visual monitoring is required every 30 minutes
C. The client must be released immediately upon request
D. A face-to-face evaluation by a provider is required within 4 hours for adults
,Correct Answer: D D. A face-to-face evaluation by a provider is required within 4 hours
for adults [CORRECT] Rationale: CMS regulations require a face-to-face evaluation
within 1 hour for children/adolescents and 4 hours for adults; orders must be obtained
before application (not within 1 hour after), and continuous monitoring (not every 30
minutes) is required. Option C is incorrect as release depends on safety assessment.
Question 5 A client tells the nurse, "I have a plan to hurt my neighbor because he is
spying on me." The nurse understands that this statement requires which mandatory
action?
A. Maintain confidentiality as this is part of the therapeutic relationship
B. Assess the client's perception of reality before taking action
C. Warn the intended victim and notify law enforcement per duty to warn statutes
D. Document the statement and continue routine monitoring
Correct Answer: C C. Warn the intended victim and notify law enforcement per duty to
warn statutes [CORRECT] Rationale: The Tarasoff duty to warn mandates breaking
confidentiality when a client presents a credible threat to a specific individual. Options
A and D place the potential victim at risk, while B delays necessary protective action.
Question 6 A psychiatric unit is implementing trauma-informed care principles. Which
nursing action best aligns with this framework?
A. Establishing strict routines to provide predictability for all clients
B. Asking clients for permission before entering personal space or touching
C. Limiting client choices to reduce anxiety and confusion
D. Using seclusion as a first-line intervention for agitated behavior
Correct Answer: B B. Asking clients for permission before entering personal space or
touching [CORRECT] Rationale: Trauma-informed care emphasizes safety,
trustworthiness, choice, collaboration, and empowerment; asking permission respects
autonomy and reduces re-traumatization. Options A and C limit autonomy, while D
contradicts trauma-informed principles.
, Question 7 Which of the following is the nurse's priority responsibility when obtaining
informed consent for electroconvulsive therapy (ECT)?
A. Explain the procedure, risks, benefits, and alternatives to the client
B. Obtain the client's signature on the consent form
C. Ensure a family member is present to witness the consent
D. Verify that the client has tried at least three antidepressant medications first
Correct Answer: A A. Explain the procedure, risks, benefits, and alternatives to the
client [CORRECT] Rationale: Informed consent requires ensuring the client
understands the procedure, risks, benefits, and alternatives; the nurse verifies
understanding but the provider obtains consent. Option B alone is insufficient without
comprehension, C is not required, and D describes treatment resistance criteria, not
consent requirements.
Question 8 A client with bipolar disorder is admitted involuntarily after manic
behavior endangered others. The nurse understands that involuntary commitment
criteria include which elements?
A. The client must agree to voluntary admission within 24 hours
B. The client presents a danger to self or others or is gravely disabled
C. The client must have a diagnosed severe mental illness
D. The client's family must request the involuntary admission
Correct Answer: B B. The client presents a danger to self or others or is gravely
disabled [CORRECT] Rationale: Involuntary commitment requires imminent danger to
self/others or inability to care for basic needs (grave disability); a specific diagnosis (C)
or family request (D) alone is insufficient, and option A describes voluntary conversion,
not commitment criteria.
