NURS 222 | NURS222 Exam 4: Mental Health - WCU
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client who just lost their home in a fire. Which type of crisis is the
client experiencing?
A. Maturational crisis
B. Situational crisis
C. Developmental crisis
D. Adventitious crisis
Correct Answer: D
Rationale: An adventitious crisis results from unplanned and accidental events such as
natural disasters or crimes of violence. The loss of a home due to a fire falls under this
category because it is an external disaster. Situational crises arise from specific life events
like job loss or illness. Maturational crises are related to developmental stages like
marriage or retirement. Identifying the type of crisis helps the nurse determine the
appropriate intervention strategy.
2. When performing a suicide risk assessment, which question is the nurse’s priority?
A. ‘Why are you feeling so sad lately?’
B. ‘Do you have a plan to hurt yourself?’
C. ‘How long have you felt this way?’
D. ‘Does your family know how you feel?’
Correct Answer: B
Rationale: The nurse’s priority is to determine the immediate risk of self-harm by
assessing the presence of a specific plan. Asking directly about suicidal ideation and intent
is the most effective way to gauge lethality. Understanding the plan allows the nurse to
intervene and ensure the client’s safety. Other questions gather useful history but do not
address immediate life-threatening risks. Direct communication is essential in emergency
psychiatric care to prevent successful suicide attempts.
3. A client is admitted involuntarily to a psychiatric unit. Which right does the client still
maintain?
A. The right to refuse psychotropic medications.
B. The right to leave against medical advice.
C. The right to carry personal weapons.
,D. The right to ignore all unit safety rules.
Correct Answer: A
Rationale: Involuntary admission does not automatically strip a client of their right to
refuse treatment or medications. Unless a court has ruled the client incompetent or an
emergency exists, they can decline prescribed drugs. The client does not have the right to
leave since they are held for safety reasons. Rights regarding personal safety and the safety
of others take precedence over some liberties. Understanding these legal nuances is vital
for psychiatric nurses providing ethical care.
4. During a crisis intervention, what is the primary goal of the nurse?
A. To help the client achieve a higher level of functioning than before.
B. To identify the deep-rooted childhood causes of the crisis.
C. To return the client to their pre-crisis level of functioning.
D. To prescribe long-term psychotherapy for personality changes.
Correct Answer: C
Rationale: The primary goal of crisis intervention is to stabilize the client and return them
to their previous level of functioning. Crisis is a time-limited state where usual coping
mechanisms fail. The nurse focuses on the immediate problem rather than long-term
psychological restructuring. While growth can occur, the immediate priority is resolution
of the acute distress. This approach ensures that the client’s equilibrium is restored as
quickly as possible.
5. Which statement by a client represents a covert suicidal comment?
A. ‘I am going to kill myself tonight.’
B. ‘Everything will be fine once I am gone.’
C. ‘I wish I were dead.’
D. ‘I have a gun in my car to end it.’
Correct Answer: B
Rationale: Covert statements are indirect hints about suicidal ideation that require further
clarification from the nurse. The phrase ‘everything will be fine once I am gone’ implies a
permanent departure without stating the method or intent clearly. Overt statements are
direct and unmistakable, such as explicitly mentioning killing oneself. Nurses must be alert
to these subtle cues to perform a thorough risk assessment. Recognizing covert messages is
a critical skill in identifying hidden distress in patients.
6. A nurse is caring for a client in seclusion. How often must the nurse document the client’s
status?
A. Only when the client becomes aggressive.
, B. Once per shift.
C. Every 4 hours.
D. Every 15 to 30 minutes.
Correct Answer: D
Rationale: Standard safety protocols require documentation of a client in seclusion or
restraints every 15 to 30 minutes. This monitoring ensures the client’s physical safety,
hydration, and nutritional needs are met. The nurse must check for skin integrity and the
necessity of continued restrictive measures. Documentation must include the client’s
behavior and the nursing interventions provided. Strict adherence to these timelines is a
legal and ethical requirement in psychiatric nursing.
7. Which phase of crisis is characterized by the use of trial-and-error attempts to solve the
problem?
A. Phase 1
B. Phase 2
C. Phase 4
D. Phase 3
Correct Answer: D
Rationale: In Phase 3 of a crisis, the individual uses trial-and-error methods to resolve the
stressful situation. If these attempts fail, the person may experience severe anxiety or
panic. Phase 1 involves a rise in tension, while Phase 2 involves increased discomfort when
initial coping fails. Phase 4 is the point of breakdown or potential resolution with
significant intervention. Recognizing these phases helps the nurse apply the correct level of
therapeutic support.
8. A client states, ‘I just can’t take it anymore.’ Which response by the nurse is the most
therapeutic?
A. ‘Why do you feel that way?’
B. ‘You shouldn’t say things like that.’
C. ‘Are you thinking of hurting yourself?’
D. ‘I’m sure things will get better soon.’
Correct Answer: C
Rationale: This response directly addresses the potential for self-harm and clarifies the
client’s vague statement. In mental health nursing, direct questioning about suicide is
necessary when a client expresses hopelessness. Asking ‘why’ can be perceived as
accusatory and may shut down communication. Offering false reassurances or judgmental
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client who just lost their home in a fire. Which type of crisis is the
client experiencing?
A. Maturational crisis
B. Situational crisis
C. Developmental crisis
D. Adventitious crisis
Correct Answer: D
Rationale: An adventitious crisis results from unplanned and accidental events such as
natural disasters or crimes of violence. The loss of a home due to a fire falls under this
category because it is an external disaster. Situational crises arise from specific life events
like job loss or illness. Maturational crises are related to developmental stages like
marriage or retirement. Identifying the type of crisis helps the nurse determine the
appropriate intervention strategy.
2. When performing a suicide risk assessment, which question is the nurse’s priority?
A. ‘Why are you feeling so sad lately?’
B. ‘Do you have a plan to hurt yourself?’
C. ‘How long have you felt this way?’
D. ‘Does your family know how you feel?’
Correct Answer: B
Rationale: The nurse’s priority is to determine the immediate risk of self-harm by
assessing the presence of a specific plan. Asking directly about suicidal ideation and intent
is the most effective way to gauge lethality. Understanding the plan allows the nurse to
intervene and ensure the client’s safety. Other questions gather useful history but do not
address immediate life-threatening risks. Direct communication is essential in emergency
psychiatric care to prevent successful suicide attempts.
3. A client is admitted involuntarily to a psychiatric unit. Which right does the client still
maintain?
A. The right to refuse psychotropic medications.
B. The right to leave against medical advice.
C. The right to carry personal weapons.
,D. The right to ignore all unit safety rules.
Correct Answer: A
Rationale: Involuntary admission does not automatically strip a client of their right to
refuse treatment or medications. Unless a court has ruled the client incompetent or an
emergency exists, they can decline prescribed drugs. The client does not have the right to
leave since they are held for safety reasons. Rights regarding personal safety and the safety
of others take precedence over some liberties. Understanding these legal nuances is vital
for psychiatric nurses providing ethical care.
4. During a crisis intervention, what is the primary goal of the nurse?
A. To help the client achieve a higher level of functioning than before.
B. To identify the deep-rooted childhood causes of the crisis.
C. To return the client to their pre-crisis level of functioning.
D. To prescribe long-term psychotherapy for personality changes.
Correct Answer: C
Rationale: The primary goal of crisis intervention is to stabilize the client and return them
to their previous level of functioning. Crisis is a time-limited state where usual coping
mechanisms fail. The nurse focuses on the immediate problem rather than long-term
psychological restructuring. While growth can occur, the immediate priority is resolution
of the acute distress. This approach ensures that the client’s equilibrium is restored as
quickly as possible.
5. Which statement by a client represents a covert suicidal comment?
A. ‘I am going to kill myself tonight.’
B. ‘Everything will be fine once I am gone.’
C. ‘I wish I were dead.’
D. ‘I have a gun in my car to end it.’
Correct Answer: B
Rationale: Covert statements are indirect hints about suicidal ideation that require further
clarification from the nurse. The phrase ‘everything will be fine once I am gone’ implies a
permanent departure without stating the method or intent clearly. Overt statements are
direct and unmistakable, such as explicitly mentioning killing oneself. Nurses must be alert
to these subtle cues to perform a thorough risk assessment. Recognizing covert messages is
a critical skill in identifying hidden distress in patients.
6. A nurse is caring for a client in seclusion. How often must the nurse document the client’s
status?
A. Only when the client becomes aggressive.
, B. Once per shift.
C. Every 4 hours.
D. Every 15 to 30 minutes.
Correct Answer: D
Rationale: Standard safety protocols require documentation of a client in seclusion or
restraints every 15 to 30 minutes. This monitoring ensures the client’s physical safety,
hydration, and nutritional needs are met. The nurse must check for skin integrity and the
necessity of continued restrictive measures. Documentation must include the client’s
behavior and the nursing interventions provided. Strict adherence to these timelines is a
legal and ethical requirement in psychiatric nursing.
7. Which phase of crisis is characterized by the use of trial-and-error attempts to solve the
problem?
A. Phase 1
B. Phase 2
C. Phase 4
D. Phase 3
Correct Answer: D
Rationale: In Phase 3 of a crisis, the individual uses trial-and-error methods to resolve the
stressful situation. If these attempts fail, the person may experience severe anxiety or
panic. Phase 1 involves a rise in tension, while Phase 2 involves increased discomfort when
initial coping fails. Phase 4 is the point of breakdown or potential resolution with
significant intervention. Recognizing these phases helps the nurse apply the correct level of
therapeutic support.
8. A client states, ‘I just can’t take it anymore.’ Which response by the nurse is the most
therapeutic?
A. ‘Why do you feel that way?’
B. ‘You shouldn’t say things like that.’
C. ‘Are you thinking of hurting yourself?’
D. ‘I’m sure things will get better soon.’
Correct Answer: C
Rationale: This response directly addresses the potential for self-harm and clarifies the
client’s vague statement. In mental health nursing, direct questioning about suicide is
necessary when a client expresses hopelessness. Asking ‘why’ can be perceived as
accusatory and may shut down communication. Offering false reassurances or judgmental
