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 wildfire. Which type of crisis is the
client experiencing?
A. Maturational crisis
B. Adventitious crisis
C. Situational crisis
D. Developmental crisis
Correct Answer: B
Rationale: An adventitious crisis is an unplanned and accidental event that is not part of
everyday life. This type of crisis results from natural disasters, national disasters, or crimes
of violence. The loss of a home due to a wildfire is a clear example of a natural disaster.
Nurses must focus on immediate safety and basic needs for these clients. Providing
psychological first aid is a critical intervention during the acute phase of an adventitious
crisis.
2. The primary goal of crisis intervention is to help the client:
A. Develop a long-term personality change
B. Understand the psychological root of the problem
C. Return to the prior level of functioning
D. Learn to manage chronic mental illness
Correct Answer: C
Rationale: The main focus of crisis intervention is to assist the individual in returning to
their pre-crisis level of functioning. Crisis intervention is a short-term, directive therapy
that usually lasts between four to six weeks. It does not aim for major personality changes
or long-term psychotherapy goals. The nurse works on stabilizing the client and resolving
the immediate problem at hand. Successfully resolving a crisis can lead to personal growth
and improved coping mechanisms.
3. A college student fails an important exam and states, ‘I’m a total failure and will never
graduate.’ This is an example of which crisis phase?
A. Phase 1
B. Phase 4
C. Phase 3
,D. Phase 2
Correct Answer: D
Rationale: In Phase 2 of a crisis, the individual’s usual defensive responses fail and anxiety
continues to rise. The person feels a sense of helplessness and may experience extreme
distress or disorganized thinking. The student’s statement reflects the growing inadequacy
of their normal coping skills to handle the academic setback. During this phase, the nurse
should assess the client’s perception of the event. Support systems and internal resources
are vital to prevent progression to Phase 3.
4. Which statement by a client requires immediate follow-up by the nurse to assess for
suicidal ideation?
A. ‘I am so tired of being sick every day.’
B. ‘Everything will be better once I am gone.’
C. ‘I feel like I’m losing my mind with all this stress.’
D. ‘I wish I could just sleep for a whole week.’
Correct Answer: B
Rationale: The statement ‘Everything will be better once I am gone’ is a covert suicidal
ideation that suggests a plan or intent to end one’s life. Nurses must be alert to indirect
comments that hint at a desire to die. When a client makes such a statement, the nurse
must ask directly about suicide. Assessing the lethality of the intent is the highest priority
for client safety. Immediate intervention is required to ensure the client is placed in a
secure environment.
5. A client is admitted following a suicide attempt. Which nursing intervention is the highest
priority?
A. Assessing the client’s coping skills
B. Encouraging the client to attend group therapy
C. Implementing one-on-one observation
D. Teaching the client about medication side effects
Correct Answer: C
Rationale: Safety is the absolute priority for a client who has recently attempted suicide.
One-on-one observation ensures that the client is never left alone and is protected from
self-harm. This level of supervision allows for immediate intervention if the client displays
dangerous behaviors. While coping skills and group therapy are important, they are
addressed after the client is stable. The nurse must document the client’s activities and
mood every 15 minutes or as per facility protocol.
, 6. Which of the following methods of suicide is considered high lethality?
A. Slashing wrists
B. Gunshot to the head
C. Ingesting ten aspirin tablets
D. Inhaling natural gas
Correct Answer: B
Rationale: Lethality refers to how quickly and effectively a method will result in death. Use
of a firearm is considered a high-lethality (hard) method because there is little time for
rescue. Lower lethality (soft) methods include things like cutting wrists or ingesting pills,
which allow for a window of intervention. Assessing the lethality of a plan is a crucial step
in a suicide risk assessment. Clients with access to high-lethality methods require the most
intensive level of supervision.
7. A nurse is using the SAD PERSONS scale to assess a client. What does the ‘S’ in the scale
stand for?
A. Social status
B. Somatic symptoms
C. Sex (Gender)
D. Severity of illness
Correct Answer: C
Rationale: The SAD PERSONS scale is a clinical tool used to assess the risk factors for
suicide. The ‘S’ stands for Sex, as statistics show that while women attempt suicide more
often, men are more likely to complete it. Other factors in the scale include Age, Depression,
Previous attempt, Ethanol use, and Rational thinking loss. Using standardized tools helps
nurses quantify risk and communicate findings to the healthcare team. This objective
assessment guides the level of care and precautions needed for the client.
8. A client experiencing a maturational crisis would likely be dealing with which scenario?
A. The sudden death of a spouse in a car accident
B. A child leaving home for college (Empty Nest)
C. The loss of a job due to corporate downsizing
D. Physical assault during a robbery
Correct Answer: B
Rationale: Maturational crises occur during normal life transitions as a person moves
through developmental stages. Events such as marriage, retirement, or a child leaving
home require the individual to develop new coping skills. If the person cannot adapt to
Updated and Latest Questions and Correct
Answers with Rationale
1. A nurse is assessing a client who just lost their home in a wildfire. Which type of crisis is the
client experiencing?
A. Maturational crisis
B. Adventitious crisis
C. Situational crisis
D. Developmental crisis
Correct Answer: B
Rationale: An adventitious crisis is an unplanned and accidental event that is not part of
everyday life. This type of crisis results from natural disasters, national disasters, or crimes
of violence. The loss of a home due to a wildfire is a clear example of a natural disaster.
Nurses must focus on immediate safety and basic needs for these clients. Providing
psychological first aid is a critical intervention during the acute phase of an adventitious
crisis.
2. The primary goal of crisis intervention is to help the client:
A. Develop a long-term personality change
B. Understand the psychological root of the problem
C. Return to the prior level of functioning
D. Learn to manage chronic mental illness
Correct Answer: C
Rationale: The main focus of crisis intervention is to assist the individual in returning to
their pre-crisis level of functioning. Crisis intervention is a short-term, directive therapy
that usually lasts between four to six weeks. It does not aim for major personality changes
or long-term psychotherapy goals. The nurse works on stabilizing the client and resolving
the immediate problem at hand. Successfully resolving a crisis can lead to personal growth
and improved coping mechanisms.
3. A college student fails an important exam and states, ‘I’m a total failure and will never
graduate.’ This is an example of which crisis phase?
A. Phase 1
B. Phase 4
C. Phase 3
,D. Phase 2
Correct Answer: D
Rationale: In Phase 2 of a crisis, the individual’s usual defensive responses fail and anxiety
continues to rise. The person feels a sense of helplessness and may experience extreme
distress or disorganized thinking. The student’s statement reflects the growing inadequacy
of their normal coping skills to handle the academic setback. During this phase, the nurse
should assess the client’s perception of the event. Support systems and internal resources
are vital to prevent progression to Phase 3.
4. Which statement by a client requires immediate follow-up by the nurse to assess for
suicidal ideation?
A. ‘I am so tired of being sick every day.’
B. ‘Everything will be better once I am gone.’
C. ‘I feel like I’m losing my mind with all this stress.’
D. ‘I wish I could just sleep for a whole week.’
Correct Answer: B
Rationale: The statement ‘Everything will be better once I am gone’ is a covert suicidal
ideation that suggests a plan or intent to end one’s life. Nurses must be alert to indirect
comments that hint at a desire to die. When a client makes such a statement, the nurse
must ask directly about suicide. Assessing the lethality of the intent is the highest priority
for client safety. Immediate intervention is required to ensure the client is placed in a
secure environment.
5. A client is admitted following a suicide attempt. Which nursing intervention is the highest
priority?
A. Assessing the client’s coping skills
B. Encouraging the client to attend group therapy
C. Implementing one-on-one observation
D. Teaching the client about medication side effects
Correct Answer: C
Rationale: Safety is the absolute priority for a client who has recently attempted suicide.
One-on-one observation ensures that the client is never left alone and is protected from
self-harm. This level of supervision allows for immediate intervention if the client displays
dangerous behaviors. While coping skills and group therapy are important, they are
addressed after the client is stable. The nurse must document the client’s activities and
mood every 15 minutes or as per facility protocol.
, 6. Which of the following methods of suicide is considered high lethality?
A. Slashing wrists
B. Gunshot to the head
C. Ingesting ten aspirin tablets
D. Inhaling natural gas
Correct Answer: B
Rationale: Lethality refers to how quickly and effectively a method will result in death. Use
of a firearm is considered a high-lethality (hard) method because there is little time for
rescue. Lower lethality (soft) methods include things like cutting wrists or ingesting pills,
which allow for a window of intervention. Assessing the lethality of a plan is a crucial step
in a suicide risk assessment. Clients with access to high-lethality methods require the most
intensive level of supervision.
7. A nurse is using the SAD PERSONS scale to assess a client. What does the ‘S’ in the scale
stand for?
A. Social status
B. Somatic symptoms
C. Sex (Gender)
D. Severity of illness
Correct Answer: C
Rationale: The SAD PERSONS scale is a clinical tool used to assess the risk factors for
suicide. The ‘S’ stands for Sex, as statistics show that while women attempt suicide more
often, men are more likely to complete it. Other factors in the scale include Age, Depression,
Previous attempt, Ethanol use, and Rational thinking loss. Using standardized tools helps
nurses quantify risk and communicate findings to the healthcare team. This objective
assessment guides the level of care and precautions needed for the client.
8. A client experiencing a maturational crisis would likely be dealing with which scenario?
A. The sudden death of a spouse in a car accident
B. A child leaving home for college (Empty Nest)
C. The loss of a job due to corporate downsizing
D. Physical assault during a robbery
Correct Answer: B
Rationale: Maturational crises occur during normal life transitions as a person moves
through developmental stages. Events such as marriage, retirement, or a child leaving
home require the individual to develop new coping skills. If the person cannot adapt to
