Saunders Comprehensive Review for Mental Health Nursing
– Complete Study Guide, Exam Prep Notes, Practice
Questions, Rationales & Key Concepts for
Psychiatric/Mental Health Nursing Success
Question 1: A client diagnosed with major depressive disorder states, "I don't see the point in
living anymore." Which nursing action is the priority?
A. Ask the client to sign a no-suicide contract
B. Explore the client's reasons for feeling hopeless
C. Assess the client's suicide plan, means, and intent
D. Provide reassurance that things will get better
CORRECT ANSWER: C. Assess the client's suicide plan, means, and intent
Rationale: When a client expresses suicidal ideation, the nurse's priority is to conduct a
thorough suicide risk assessment, including evaluating the presence of a specific plan, access to
means, and level of intent. This information determines the immediacy of intervention and
level of supervision required. While exploring feelings and providing support are important,
safety assessment takes precedence. No-suicide contracts are not reliable standalone
interventions and should not replace comprehensive assessment.
Question 2: Which therapeutic communication technique is demonstrated when the nurse
states, "You seem upset about the news you received today"?
A. Offering advice
B. Making observations
C. Asking closed-ended questions
D. Changing the subject
CORRECT ANSWER: B. Making observations
Rationale: Making observations involves verbally acknowledging the client's behavior, mood, or
affect to encourage exploration of feelings. This technique validates the client's experience and
opens dialogue without imposing the nurse's interpretation. Offering advice, asking closed-
ended questions, and changing the subject are nontherapeutic techniques that can block
communication and diminish client autonomy.
Question 3: A client with schizophrenia is experiencing auditory hallucinations commanding
self-harm. Which nursing intervention is most appropriate?
A. Tell the client the voices are not real
B. Engage the client in a structured, reality-based activity
C. Leave the client alone to reduce stimulation
D. Argue with the client about the content of the hallucinations
CORRECT ANSWER: B. Engage the client in a structured, reality-based activity
Rationale: Engaging a client experiencing command hallucinations in a structured, reality-based
activity helps redirect focus, provides external stimulation to compete with internal stimuli, and
enhances safety through nurse presence. Telling the client the voices are not real or arguing
about hallucinations invalidates the client's experience and may increase agitation. Leaving the
client alone increases risk when command hallucinations involve self-harm.
Question 4: Which statement by a client with bipolar disorder in the manic phase indicates a
need for immediate nursing intervention?
,A. "I've been writing poetry all night."
B. "I just bought three cars online with my credit card."
C. "I feel like I can accomplish anything right now."
D. "I haven't slept much, but I don't feel tired."
CORRECT ANSWER: B. "I just bought three cars online with my credit card."
Rationale: Impulsive, financially destructive behaviors such as excessive spending during mania
pose significant safety and legal risks requiring immediate intervention to prevent harm. While
decreased need for sleep, grandiosity, and increased goal-directed activity are characteristic of
mania, behaviors with immediate consequential harm take priority. The nurse should
implement safety measures, limit access to finances, and collaborate with the treatment team.
Question 5: A client taking clozapine reports a sore throat and fever. Which action should the
nurse take first?
A. Administer acetaminophen for fever
B. Notify the healthcare provider immediately
C. Encourage increased fluid intake
D. Document the symptoms in the chart
CORRECT ANSWER: B. Notify the healthcare provider immediately
Rationale: Clozapine carries a black box warning for agranulocytosis, a potentially life-
threatening drop in white blood cell count. Sore throat and fever are early signs of infection
that may indicate agranulocytosis. Immediate notification of the healthcare provider is critical
for prompt laboratory evaluation (absolute neutrophil count) and potential discontinuation of
the medication. Symptomatic treatment or documentation alone delays essential intervention.
Question 6: Which defense mechanism is demonstrated when a client with alcohol use
disorder states, "I only drink because my job is so stressful"?
A. Denial
B. Projection
C. Rationalization
D. Sublimation
CORRECT ANSWER: C. Rationalization
Rationale: Rationalization involves creating logical but false explanations to justify unacceptable
behaviors or feelings. The client is attributing alcohol use to external stressors rather than
acknowledging personal responsibility. Denial would involve refusing to acknowledge the
problem exists; projection involves attributing one's own feelings to others; sublimation
channels unacceptable impulses into socially acceptable activities.
Question 7: A client diagnosed with post-traumatic stress disorder (PTSD) experiences a
flashback during group therapy. What is the nurse's best initial action?
A. Ask the client to describe the traumatic event in detail
B. Gently guide the client to focus on the present environment
C. End the group session immediately
D. Administer a PRN antianxiety medication
CORRECT ANSWER: B. Gently guide the client to focus on the present environment
,Rationale: During a flashback, the client is re-experiencing trauma and is disconnected from
present reality. Grounding techniques that orient the client to the here-and-now (e.g., naming
objects in the room, feeling feet on the floor) help reduce dissociation and anxiety. Asking for
trauma details may retraumatize; ending the group may increase isolation; medication should
not be the first-line response without assessment and nonpharmacologic interventions.
Question 8: Which finding is most indicative of neuroleptic malignant syndrome (NMS) in a
client taking antipsychotic medication?
A. Mild tremor and restlessness
B. Muscle rigidity, high fever, and altered mental status
C. Dry mouth and blurred vision
D. Weight gain and increased appetite
CORRECT ANSWER: B. Muscle rigidity, high fever, and altered mental status
Rationale: Neuroleptic malignant syndrome is a rare but life-threatening reaction to
antipsychotics characterized by the classic tetrad: muscle rigidity, hyperthermia, altered mental
status, and autonomic instability. Immediate discontinuation of the antipsychotic and
emergency medical intervention are required. Mild tremor and restlessness suggest akathisia;
dry mouth and blurred vision are anticholinergic side effects; weight gain is a metabolic side
effect.
Question 9: A client with obsessive-compulsive disorder (OCD) spends hours washing hands.
Which nursing intervention is most therapeutic?
A. Allow the client to complete the ritual to reduce anxiety
B. Gradually limit the time allowed for handwashing
C. Tell the client the behavior is irrational and must stop
D. Ignore the behavior to avoid reinforcing it
CORRECT ANSWER: B. Gradually limit the time allowed for handwashing
Rationale: Behavioral interventions for OCD, such as exposure and response prevention, involve
gradually reducing ritualistic behaviors while supporting the client through anxiety. Abruptly
stopping rituals or labeling them irrational increases distress and resistance. Allowing unlimited
rituals reinforces the compulsive cycle. Ignoring the behavior fails to provide needed
therapeutic support and structure.
Question 10: Which statement by a nursing student indicates understanding of therapeutic
milieu?
A. "The milieu focuses on controlling client behavior through strict rules."
B. "The milieu uses the environment and social interactions to promote healing."
C. "The milieu is primarily the responsibility of the psychiatrist."
D. "The milieu is only effective in inpatient settings."
CORRECT ANSWER: B. "The milieu uses the environment and social interactions to promote
healing."
Rationale: A therapeutic milieu is a structured environment that uses interpersonal
interactions, group activities, and consistent expectations to promote safety, skill-building, and
emotional growth. It is a collaborative, multidisciplinary approach applicable in various settings.
, It emphasizes empowerment and normalization, not control; involves all staff and peers; and
can be adapted to outpatient and community contexts.
Question 11: A client diagnosed with borderline personality disorder states, "You're the only
nurse who cares about me; the others are all cruel." Which phenomenon is the client
demonstrating?
A. Dissociation
B. Splitting
C. Projection
D. Undoing
CORRECT ANSWER: B. Splitting
Rationale: Splitting is a defense mechanism common in borderline personality disorder where
the client views people or situations as all good or all bad, with no integration of positive and
negative qualities. This black-and-white thinking can strain therapeutic relationships.
Dissociation involves detachment from reality; projection attributes one's own feelings to
others; undoing involves performing an action to negate a previous unacceptable thought or
behavior.
Question 12: Which assessment finding is most concerning for a client admitted with severe
alcohol withdrawal?
A. Mild anxiety and insomnia
B. Tremors and diaphoresis
C. Hallucinations and agitation
D. Seizure activity and delirium tremens
CORRECT ANSWER: D. Seizure activity and delirium tremens
Rationale: Seizures and delirium tremens (DTs) represent the most severe, life-threatening
complications of alcohol withdrawal, with mortality rates up to 5% if untreated. DTs include
confusion, hallucinations, autonomic hyperactivity, and fever requiring intensive monitoring
and benzodiazepine management. While anxiety, tremors, and hallucinations indicate
withdrawal progression, seizures and DTs demand immediate, aggressive intervention.
Question 13: A client with anorexia nervosa has a body mass index (BMI) of 14. Which
nursing diagnosis is the priority?
A. Disturbed body image
B. Imbalanced nutrition: less than body requirements
C. Ineffective coping
D. Chronic low self-esteem
CORRECT ANSWER: B. Imbalanced nutrition: less than body requirements
Rationale: With a BMI of 14 (severe malnutrition), physiological stability takes precedence per
Maslow's hierarchy. Cardiac complications, electrolyte imbalances, and organ failure pose
immediate life threats requiring nutritional rehabilitation. While psychological issues are central
to anorexia, medical stabilization is the foundation for subsequent therapeutic work on body
image, coping, and self-esteem.
Question 14: Which statement by a client starting sertraline indicates the need for further
teaching?
– Complete Study Guide, Exam Prep Notes, Practice
Questions, Rationales & Key Concepts for
Psychiatric/Mental Health Nursing Success
Question 1: A client diagnosed with major depressive disorder states, "I don't see the point in
living anymore." Which nursing action is the priority?
A. Ask the client to sign a no-suicide contract
B. Explore the client's reasons for feeling hopeless
C. Assess the client's suicide plan, means, and intent
D. Provide reassurance that things will get better
CORRECT ANSWER: C. Assess the client's suicide plan, means, and intent
Rationale: When a client expresses suicidal ideation, the nurse's priority is to conduct a
thorough suicide risk assessment, including evaluating the presence of a specific plan, access to
means, and level of intent. This information determines the immediacy of intervention and
level of supervision required. While exploring feelings and providing support are important,
safety assessment takes precedence. No-suicide contracts are not reliable standalone
interventions and should not replace comprehensive assessment.
Question 2: Which therapeutic communication technique is demonstrated when the nurse
states, "You seem upset about the news you received today"?
A. Offering advice
B. Making observations
C. Asking closed-ended questions
D. Changing the subject
CORRECT ANSWER: B. Making observations
Rationale: Making observations involves verbally acknowledging the client's behavior, mood, or
affect to encourage exploration of feelings. This technique validates the client's experience and
opens dialogue without imposing the nurse's interpretation. Offering advice, asking closed-
ended questions, and changing the subject are nontherapeutic techniques that can block
communication and diminish client autonomy.
Question 3: A client with schizophrenia is experiencing auditory hallucinations commanding
self-harm. Which nursing intervention is most appropriate?
A. Tell the client the voices are not real
B. Engage the client in a structured, reality-based activity
C. Leave the client alone to reduce stimulation
D. Argue with the client about the content of the hallucinations
CORRECT ANSWER: B. Engage the client in a structured, reality-based activity
Rationale: Engaging a client experiencing command hallucinations in a structured, reality-based
activity helps redirect focus, provides external stimulation to compete with internal stimuli, and
enhances safety through nurse presence. Telling the client the voices are not real or arguing
about hallucinations invalidates the client's experience and may increase agitation. Leaving the
client alone increases risk when command hallucinations involve self-harm.
Question 4: Which statement by a client with bipolar disorder in the manic phase indicates a
need for immediate nursing intervention?
,A. "I've been writing poetry all night."
B. "I just bought three cars online with my credit card."
C. "I feel like I can accomplish anything right now."
D. "I haven't slept much, but I don't feel tired."
CORRECT ANSWER: B. "I just bought three cars online with my credit card."
Rationale: Impulsive, financially destructive behaviors such as excessive spending during mania
pose significant safety and legal risks requiring immediate intervention to prevent harm. While
decreased need for sleep, grandiosity, and increased goal-directed activity are characteristic of
mania, behaviors with immediate consequential harm take priority. The nurse should
implement safety measures, limit access to finances, and collaborate with the treatment team.
Question 5: A client taking clozapine reports a sore throat and fever. Which action should the
nurse take first?
A. Administer acetaminophen for fever
B. Notify the healthcare provider immediately
C. Encourage increased fluid intake
D. Document the symptoms in the chart
CORRECT ANSWER: B. Notify the healthcare provider immediately
Rationale: Clozapine carries a black box warning for agranulocytosis, a potentially life-
threatening drop in white blood cell count. Sore throat and fever are early signs of infection
that may indicate agranulocytosis. Immediate notification of the healthcare provider is critical
for prompt laboratory evaluation (absolute neutrophil count) and potential discontinuation of
the medication. Symptomatic treatment or documentation alone delays essential intervention.
Question 6: Which defense mechanism is demonstrated when a client with alcohol use
disorder states, "I only drink because my job is so stressful"?
A. Denial
B. Projection
C. Rationalization
D. Sublimation
CORRECT ANSWER: C. Rationalization
Rationale: Rationalization involves creating logical but false explanations to justify unacceptable
behaviors or feelings. The client is attributing alcohol use to external stressors rather than
acknowledging personal responsibility. Denial would involve refusing to acknowledge the
problem exists; projection involves attributing one's own feelings to others; sublimation
channels unacceptable impulses into socially acceptable activities.
Question 7: A client diagnosed with post-traumatic stress disorder (PTSD) experiences a
flashback during group therapy. What is the nurse's best initial action?
A. Ask the client to describe the traumatic event in detail
B. Gently guide the client to focus on the present environment
C. End the group session immediately
D. Administer a PRN antianxiety medication
CORRECT ANSWER: B. Gently guide the client to focus on the present environment
,Rationale: During a flashback, the client is re-experiencing trauma and is disconnected from
present reality. Grounding techniques that orient the client to the here-and-now (e.g., naming
objects in the room, feeling feet on the floor) help reduce dissociation and anxiety. Asking for
trauma details may retraumatize; ending the group may increase isolation; medication should
not be the first-line response without assessment and nonpharmacologic interventions.
Question 8: Which finding is most indicative of neuroleptic malignant syndrome (NMS) in a
client taking antipsychotic medication?
A. Mild tremor and restlessness
B. Muscle rigidity, high fever, and altered mental status
C. Dry mouth and blurred vision
D. Weight gain and increased appetite
CORRECT ANSWER: B. Muscle rigidity, high fever, and altered mental status
Rationale: Neuroleptic malignant syndrome is a rare but life-threatening reaction to
antipsychotics characterized by the classic tetrad: muscle rigidity, hyperthermia, altered mental
status, and autonomic instability. Immediate discontinuation of the antipsychotic and
emergency medical intervention are required. Mild tremor and restlessness suggest akathisia;
dry mouth and blurred vision are anticholinergic side effects; weight gain is a metabolic side
effect.
Question 9: A client with obsessive-compulsive disorder (OCD) spends hours washing hands.
Which nursing intervention is most therapeutic?
A. Allow the client to complete the ritual to reduce anxiety
B. Gradually limit the time allowed for handwashing
C. Tell the client the behavior is irrational and must stop
D. Ignore the behavior to avoid reinforcing it
CORRECT ANSWER: B. Gradually limit the time allowed for handwashing
Rationale: Behavioral interventions for OCD, such as exposure and response prevention, involve
gradually reducing ritualistic behaviors while supporting the client through anxiety. Abruptly
stopping rituals or labeling them irrational increases distress and resistance. Allowing unlimited
rituals reinforces the compulsive cycle. Ignoring the behavior fails to provide needed
therapeutic support and structure.
Question 10: Which statement by a nursing student indicates understanding of therapeutic
milieu?
A. "The milieu focuses on controlling client behavior through strict rules."
B. "The milieu uses the environment and social interactions to promote healing."
C. "The milieu is primarily the responsibility of the psychiatrist."
D. "The milieu is only effective in inpatient settings."
CORRECT ANSWER: B. "The milieu uses the environment and social interactions to promote
healing."
Rationale: A therapeutic milieu is a structured environment that uses interpersonal
interactions, group activities, and consistent expectations to promote safety, skill-building, and
emotional growth. It is a collaborative, multidisciplinary approach applicable in various settings.
, It emphasizes empowerment and normalization, not control; involves all staff and peers; and
can be adapted to outpatient and community contexts.
Question 11: A client diagnosed with borderline personality disorder states, "You're the only
nurse who cares about me; the others are all cruel." Which phenomenon is the client
demonstrating?
A. Dissociation
B. Splitting
C. Projection
D. Undoing
CORRECT ANSWER: B. Splitting
Rationale: Splitting is a defense mechanism common in borderline personality disorder where
the client views people or situations as all good or all bad, with no integration of positive and
negative qualities. This black-and-white thinking can strain therapeutic relationships.
Dissociation involves detachment from reality; projection attributes one's own feelings to
others; undoing involves performing an action to negate a previous unacceptable thought or
behavior.
Question 12: Which assessment finding is most concerning for a client admitted with severe
alcohol withdrawal?
A. Mild anxiety and insomnia
B. Tremors and diaphoresis
C. Hallucinations and agitation
D. Seizure activity and delirium tremens
CORRECT ANSWER: D. Seizure activity and delirium tremens
Rationale: Seizures and delirium tremens (DTs) represent the most severe, life-threatening
complications of alcohol withdrawal, with mortality rates up to 5% if untreated. DTs include
confusion, hallucinations, autonomic hyperactivity, and fever requiring intensive monitoring
and benzodiazepine management. While anxiety, tremors, and hallucinations indicate
withdrawal progression, seizures and DTs demand immediate, aggressive intervention.
Question 13: A client with anorexia nervosa has a body mass index (BMI) of 14. Which
nursing diagnosis is the priority?
A. Disturbed body image
B. Imbalanced nutrition: less than body requirements
C. Ineffective coping
D. Chronic low self-esteem
CORRECT ANSWER: B. Imbalanced nutrition: less than body requirements
Rationale: With a BMI of 14 (severe malnutrition), physiological stability takes precedence per
Maslow's hierarchy. Cardiac complications, electrolyte imbalances, and organ failure pose
immediate life threats requiring nutritional rehabilitation. While psychological issues are central
to anorexia, medical stabilization is the foundation for subsequent therapeutic work on body
image, coping, and self-esteem.
Question 14: Which statement by a client starting sertraline indicates the need for further
teaching?
