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CPMHN(C) practice questions

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Question 1Foundations and Professional Practice of Psychiatric/Mental Health Nursing

Which nursing action best illustrates a professional boundary in the therapeutic relationship?

  1. Sharing personal relationship difficulties to show empathy and build trust.
  2. Accepting a client's gift of jewelry as a sign of appreciation.
  3. Meeting the client privately outside the unit for coffee to reduce their anxiety.
  4. Clarifying purpose, roles, and limits of the relationship early with the client. Correct answer.

Explanation

Professional boundaries define the parameters of the nurse-client relationship and protect both parties; clarifying roles and purpose early helps prevent role confusion. Self-disclosure of personal problems, accepting gifts, and meeting outside the unit can blur boundaries and create obligation or dependency.

Question 2Foundations and Professional Practice of Psychiatric/Mental Health Nursing

Which statement reflects a recovery-oriented approach in psychiatric mental health nursing?

  1. The nurse supports the client's own goals while offering information and skills. Correct answer.
  2. The nurse limits family involvement to protect the client's privacy.
  3. The nurse decides the client's goals because the care team knows what is safest.
  4. The nurse focuses mainly on symptom elimination as the only measure of success.

Explanation

Recovery-oriented practice centers the person's own goals, strengths, and choices, with clinicians collaborating rather than deciding for the client. Symptom reduction may be important, but it is not the only marker of success. Family and community supports are included with the client's consent.

Question 3Foundations and Professional Practice of Psychiatric/Mental Health Nursing

Which principle is central to trauma-informed care?

  1. Avoiding discussion of coping skills to prevent distress
  2. Requiring clients to describe traumatic events before receiving care
  3. Prioritizing safety, choice, and collaboration in all interactions Correct answer.
  4. Using seclusion to prevent emotional overload

Explanation

Trauma-informed care emphasizes safety, trustworthiness, choice, collaboration, and empowerment in every interaction. It does not require clients to disclose trauma or avoid coping discussions; coercive practices such as seclusion can re-traumatize.

Question 4Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client in acute psychosis refuses antipsychotic medication and says, "You are trying to poison me." What is the nurse's best initial action?

  1. Document the refusal and take no further action.
  2. Ask the family to sign consent on behalf of the client.
  3. Administer the medication intramuscularly because the refusal is due to psychosis.
  4. Assess decision-making capacity and follow applicable mental health law. Correct answer.

Explanation

Refusal is not automatically invalid in psychosis; the nurse must assess decision-making capacity and apply mental health law and policy. An adult with capacity may refuse treatment, and family members cannot consent on the client's behalf. Emergency treatment without consent requires legal authority.

Question 5Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client says they feel lonely and asks the nurse to be their friend on social media. Which response best maintains professional boundaries?

  1. Share details about the nurse's own social life to normalize the client's loneliness.
  2. Acknowledge the loneliness and decline social media contact as a boundary issue. Correct answer.
  3. Accept the request privately and avoid discussing it with colleagues.
  4. Give the client the nurse's personal phone number for emergencies.

Explanation

Social media friending and personal contact are boundary crossings that can blur roles, compromise confidentiality, and create dual relationships. The nurse should acknowledge the client's loneliness, reinforce the professional limits, and involve the team when boundary issues arise.

Question 6Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client discloses, "I am going to seriously hurt my ex-partner tonight. I know where they live." What is the nurse's priority?

  1. Wait to see whether the client repeats the threat before acting.
  2. Keep the disclosure confidential because the client trusted the nurse.
  3. Follow duty-to-warn/protect protocols and notify the care team immediately. Correct answer.
  4. Tell the client to call the ex-partner and apologize for the threat.

Explanation

Confidentiality is limited when a client makes a credible, serious threat against an identifiable person. The nurse must follow duty-to-protect or duty-to-warn law and agency protocol, immediately involving the care team rather than acting alone or delaying.

Question 7Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse says, "That manipulative client is just attention-seeking again." Which concept does this statement most clearly reflect?

  1. Stigma that can reduce quality of care Correct answer.
  2. Recovery-oriented language that promotes the client's hope and agency
  3. Professional boundary maintenance that protects the care team
  4. Trauma-informed communication that validates the client's distress

Explanation

Labels such as "manipulative" and "attention-seeking" are stigmatizing and can lead clinicians to dismiss the client's needs and provide poorer care. Nurses should describe observable behavior, explore antecedents and needs, and use non-judgmental language that recognizes power and bias.

Question 8Foundations and Professional Practice of Psychiatric/Mental Health Nursing

An Indigenous client says that a smudging ceremony is important for their healing. What is the most culturally safe nursing action?

  1. Tell the client that only evidence-based biomedical practices are allowed.
  2. Explore the request and advocate for space and policy support. Correct answer.
  3. Ask the client to prove that the ceremony is part of their culture.
  4. Document the request but explain that unit staff are too busy to accommodate it.

Explanation

Cultural safety requires nurses to examine power, avoid imposing biomedical norms, and advocate for culturally relevant care within safety and policy limits. Dismissing the request or demanding proof is discriminatory and can harm therapeutic trust.

Question 9Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client is agitated but not imminently dangerous. Which action best reflects the ethical principle of least restrictive care?

  1. Use seclusion because it is faster than talking with the client.
  2. Offer a quiet space and verbal de-escalation before considering seclusion. Correct answer.
  3. Apply physical restraints immediately to prevent any possible harm.
  4. Increase medication without informing the client or team.

Explanation

The least restrictive principle requires the least intrusive effective intervention that maintains safety, such as environmental change and verbal de-escalation, before restraint or seclusion. Restrictive measures require legal authority, clear justification, monitoring, and documentation.

Question 10Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse disagrees with the psychiatrist's medication plan and believes the client is at risk. What is the most appropriate professional action?

  1. Raise the concern through team communication and document the discussion. Correct answer.
  2. Discuss the concern with other clients in the unit to get their opinions.
  3. Change the medication dose independently and inform the pharmacy later.
  4. Silently follow the order to avoid conflict with the team.

Explanation

Interprofessional collaboration requires nurses to voice safety concerns through structured communication and document the discussion, while staying within their scope of practice. Silently following a disputed order or changing medication independently can endanger the client and breach accountability.

Question 11Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse meets a newly admitted client and says, "Let's talk about what you hope to get from this admission and how we will work together." Which phase of the nurse-client relationship does this statement best illustrate?

  1. Pre-interaction phase
  2. Termination phase
  3. Orientation phase Correct answer.
  4. Working phase

Explanation

The orientation phase is when the nurse and client establish trust, clarify roles and expectations, identify goals, and set the boundaries of the relationship. The working phase is where the therapeutic work of exploring problems and practicing new skills occurs. The termination phase reviews gains, consolidates learning, and plans for discharge and community follow-up.

Question 12Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client falls in the hallway of the inpatient unit and is unharmed. Which action reflects correct documentation practice?

  1. Complete an incident report and chart the objective facts in the client's record. Correct answer.
  2. Write "incident report completed" in the progress note instead of describing the event.
  3. Record only the client's subjective account and omit the nurse's observations.
  4. Ask the client to sign the incident report before the nurse documents the fall.

Explanation

Incident reports are internal risk-management documents used to track and analyze events, and they are not filed in the health record. The clinical record must still contain an objective, factual description of what happened, the nursing assessment, interventions, and notification of the physician or family. Subjective blame and opinions are omitted from both documents.

Question 13Foundations and Professional Practice of Psychiatric/Mental Health Nursing

Which element is required to demonstrate that a client has the capacity to consent to a specific treatment?

  1. Having a family member confirm that the decision seems reasonable.
  2. Being able to understand relevant information and appreciate the consequences of the decision. Correct answer.
  3. Agreeing with the treatment team's recommendation without asking questions.
  4. Having a documented diagnosis of a mental illness reviewed by the psychiatrist.

Explanation

Capacity is decision-specific and functional: the person must understand the information relevant to the decision, appreciate its reasonably foreseeable consequences, and be able to communicate a choice. A psychiatric diagnosis alone does not remove capacity, and clients are entitled to make decisions that staff consider unwise. Agreement with the team is not a criterion for capacity.

Question 14Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse is assigning tasks to an unregulated care provider (UCP) on a mental health unit. Which task is appropriate to delegate?

  1. Accompanying a stable client to the dining room and reporting observed intake. Correct answer.
  2. Completing the admission assessment and initial care plan.
  3. Monitoring the client for early signs of lithium toxicity.
  4. Teaching the client about newly prescribed lithium.

Explanation

Tasks may be delegated when they fall within the UCP's education, competence, and legislated scope, and when the outcome is predictable. The nurse remains accountable for the nursing process, including assessment, teaching, evaluation, and clinical judgment, and cannot transfer that accountability to a UCP. Monitoring for medication toxicity requires nursing assessment and interpretation.

Question 15Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client tells the nurse, "You remind me of my sister, who always let me down." Which concept does this statement best illustrate?

  1. Splitting
  2. Projection
  3. Transference Correct answer.
  4. Countertransference

Explanation

Transference occurs when a client unconsciously displaces onto the nurse feelings, expectations, and patterns from a significant past relationship. The nurse recognizes the pattern, explores it with the client, and maintains a therapeutic focus rather than reacting personally. Countertransference refers to the nurse's own emotional reactions to the client.

Question 16Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client who injects opioids tells the nurse they are not ready to stop using. Which nursing response best reflects a harm reduction approach?

  1. "Your only real option is an inpatient detoxification admission."
  2. "Let's talk about safer injection practices and where to get naloxone." Correct answer.
  3. "I will document that you are non-compliant with your treatment plan."
  4. "You cannot receive care here until you agree to abstinence-based treatment."

Explanation

Harm reduction meets people where they are and works to reduce the negative consequences of substance use without requiring abstinence as a precondition for care. Education on safer injection, naloxone distribution, and linkage to services preserve engagement and trust while reducing harms. Care is not withheld or framed as punishment when a client is not ready to stop.

Question 17Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A 15-year-old client asks the nurse not to tell their parents about their cannabis use. Which response best reflects professional and legal obligations?

  1. "I must tell your parents everything because you are a minor."
  2. "You should be the one to tell them, or I will have to call them today."
  3. "I will keep this private unless I believe you are at serious risk of harm." Correct answer.
  4. "I promise to keep everything you say completely private."

Explanation

Nurses should explain the limits of confidentiality at the beginning of the relationship: information is shared on a need-to-know basis, and confidentiality may be broken when there is a serious risk of harm to self or others, or when disclosure is required by law such as child protection legislation. A promise of absolute confidentiality is unrealistic and damages trust when it must be broken. Blanket disclosure to parents is not required for every issue.

Question 18Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client has just been released from seclusion. Which nursing action best supports recovery and meets restraint and seclusion standards?

  1. Review the experience with the client, explore triggers, and update the safety plan. Correct answer.
  2. Document that the client is calm and return promptly to routine unit tasks.
  3. Ask the client to sign a contract agreeing not to repeat the behaviour.
  4. Delay any discussion until the client's next scheduled psychiatrist appointment.

Explanation

Post-seclusion and post-restraint debriefing is an expected standard of care: staff and the client review what happened, the client's perspective, contributing triggers, and alternative strategies, and the plan of care is updated. Debriefing supports recovery, reduces re-traumatization, and informs unit-level practice improvement. Behaviour contracts are not a substitute for this review.

Question 19Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse believes a client's PRN antipsychotic is being used to manage staffing shortages rather than the client's symptoms, but the charge nurse dismisses the concern. Which concept best describes the nurse's experience?

  1. Vicarious trauma
  2. Burnout
  3. Moral distress Correct answer.
  4. Compassion fatigue

Explanation

Moral distress arises when a nurse knows the ethically right action but is constrained from taking it by institutional, hierarchical, or resource factors. It is distinct from burnout, which is a syndrome of exhaustion and depersonalization resulting from chronic workplace stress. Addressing moral distress requires voicing concerns through ethical and organizational channels rather than accepting the constraint.

Question 20Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client scores in the low-risk range on a standardized suicide risk screen but then discloses new hopelessness and recent stockpiling of medication. What is the nurse's best action?

  1. Wait for the psychiatrist to reassess the client at the next scheduled rounds.
  2. Document the low score and offer the client a no-suicide contract.
  3. Reassure the client that the screening tool shows low risk and continue the current plan.
  4. Treat the disclosure as clinically significant and complete a comprehensive risk assessment. Correct answer.

Explanation

Screening tools support but do not replace clinical judgment; a low score cannot override direct disclosure of warning signs such as hopelessness and access to means. The nurse should complete a comprehensive suicide risk assessment, address immediate safety, and escalate care as needed. Safety planning, not no-suicide contracts, is the recommended approach.

Question 21Foundations and Professional Practice of Psychiatric/Mental Health Nursing

During a mental status examination, the nurse asks a client, "What does the saying 'people in glass houses should not throw stones' mean?" Which area is the nurse assessing?

  1. Insight into the current illness
  2. Orientation to time, place, and person
  3. Abstract reasoning Correct answer.
  4. Judgment for everyday decisions

Explanation

Proverb interpretation assesses abstract reasoning, the ability to grasp meaning beyond literal words. Concrete interpretations may suggest cognitive impairment or limited abstraction. Orientation, insight, and judgment are assessed through separate questions.

Question 22Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse suspects that a 9-year-old client's injuries result from physical abuse. What is the nurse's priority action?

  1. Discuss the concern with the parents before reporting
  2. Ask the child to identify who caused the injuries
  3. Report the suspicion to the designated child protection authority Correct answer.
  4. Document the concern and wait until the next shift

Explanation

Nurses are mandated to report reasonable suspicion of child abuse to the designated child protection authority promptly. The nurse should not investigate, confront parents, or delay reporting, because these actions can increase risk. Objective findings and statements are documented, but documentation does not replace reporting.

Question 23Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client's employer telephones the inpatient unit and asks whether the client is currently admitted. Which response by the nurse is correct?

  1. Ask the employer to call the client's family instead
  2. State that no information can be shared without consent Correct answer.
  3. Confirm that the client is an inpatient on the unit
  4. Provide the client's diagnosis and treatment plan to the employer

Explanation

Confidentiality prohibits disclosing admission status or health information without the client's consent, except in specific legal situations. Even confirming that someone is a client is a disclosure. The nurse should decline the request and follow unit policy.

Question 24Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse notices wide variation in seclusion use on the unit and wants to apply evidence-based practice. Which action should the nurse take first?

  1. Implement a new seclusion policy immediately on the unit
  2. Evaluate the outcomes of the current seclusion policy
  3. Search for systematic reviews on seclusion reduction
  4. Formulate a focused clinical question about seclusion practice Correct answer.

Explanation

After identifying a clinical problem, the first evidence-based practice step is to formulate a focused question, often using PICO. Searching for evidence, appraising it, implementing change, and evaluating outcomes follow in sequence. Acting or searching before defining the question can lead to irrelevant evidence.

Question 25Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse reports a medication error immediately, and the client is unharmed. Which organizational response best reflects a just culture?

  1. Ask the nurse to write an incident report but take no further action
  2. Suspend the nurse pending an investigation into the error
  3. Restrict the nurse from administering medications for one month
  4. Examine system factors and support learning from the error Correct answer.

Explanation

Just culture responds to human error with support, system analysis, and learning rather than blame or automatic punishment. It encourages honest reporting so latent safety problems can be corrected. Reckless behavior is managed separately through fair accountability processes.

Question 26Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client nearing discharge says, "You are the only person who understands me. Can we keep meeting after I leave?" Which response best reflects the termination phase of the therapeutic relationship?

  1. Agree to meet the client privately after discharge as a friend
  2. Explore the client's feelings about ending and review progress made Correct answer.
  3. Extend the client's admission until the attachment resolves
  4. Tell the client that such feelings are inappropriate and change the topic

Explanation

Termination includes exploring feelings about separation, reviewing gains, and planning community supports. The nurse maintains professional boundaries and does not become a friend after discharge. Dismissing feelings or extending admission unnecessarily misses the therapeutic work of ending.

Question 27Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A newly admitted client with limited English proficiency appears withdrawn. Which nursing action is most culturally safe?

  1. Arrange a qualified medical interpreter for the assessment Correct answer.
  2. Defer the assessment until the client learns English
  3. Ask the client's adult child to interpret the conversation
  4. Speak more loudly and use simple words with the client

Explanation

Qualified interpreters support accurate communication, confidentiality, and informed participation in care. Family members may alter meaning, breach privacy, or experience role conflict. Speaking loudly does not address language barriers, and deferring assessment can delay needed care.

Question 28Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client with decision-making capacity refuses a recommended antidepressant after a full discussion. Which action best demonstrates advocacy?

  1. Tell the client that refusing treatment will delay discharge
  2. Respect the client's decision and continue to monitor symptoms Correct answer.
  3. Ask the family to persuade the client to accept the medication
  4. Document that the client is noncompliant with treatment

Explanation

Advocacy includes supporting informed choices and ensuring the client receives ongoing assessment and support after refusal. Coercion, family pressure, and labeling the client as noncompliant undermine autonomy. The nurse documents the informed refusal objectively and reassesses needs.

Question 29Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A client's family asks the nurse to withhold a terminal diagnosis from the client, but the client directly asks about the diagnosis. Which ethical principles are primarily in conflict?

  1. Justice and fidelity versus nonmaleficence
  2. Autonomy and veracity versus beneficence Correct answer.
  3. Paternalism and justice versus fidelity
  4. Confidentiality and veracity versus autonomy

Explanation

The client's right to self-determination and truthful information conflicts with the family's wish to protect the client from distress. Beneficence and nonmaleficence inform the family's concern, but they do not automatically override the client's autonomy. The nurse should clarify the client's preferences and cultural context while avoiding deception.

Question 30Foundations and Professional Practice of Psychiatric/Mental Health Nursing

A nurse appraises a qualitative study of clients' experiences of seclusion. Which question best evaluates the study's trustworthiness?

  1. Was the intervention delivered without blinding?
  2. Was the sample size large enough for statistical power?
  3. Were data collection and analysis audited for credibility? Correct answer.
  4. Were participants randomly assigned to treatment groups?

Explanation

Trustworthiness in qualitative research includes credibility, dependability, confirmability, and transferability, supported by audit trails, member checking, and reflexive analysis. Random assignment, statistical power, and blinding apply to quantitative designs. Applying those criteria to qualitative work reflects a mistaken appraisal.

Question 31Comprehensive Assessment and Care Planning

During a mental status examination, which component refers to the coherence, logic, and flow of a client's ideas?

  1. Cognitive function
  2. Thought content
  3. Observed affect
  4. Thought process Correct answer.

Explanation

Thought process, also called thought form, describes how ideas are organized and flow, including coherence, logical sequence, goal direction, and speed. Thought content refers to what the person is thinking about, such as delusions, obsessions, or suicidal ideas. Cognitive function covers attention, memory, and orientation, while affect is the observed emotional expression.

Question 32Comprehensive Assessment and Care Planning

A client on an inpatient unit tells the nurse, "I have a plan to kill myself tonight and I am going to do it." What is the nurse's immediate priority?

  1. Arrange a family meeting to discuss discharge planning
  2. Maintain continuous observation and remove means from the environment Correct answer.
  3. Document the statement and reassess the client at the next shift
  4. Ask the client to sign a no-suicide contract

Explanation

A stated plan with intent and an imminent timeframe is a high-risk presentation requiring immediate safety measures: continuous observation, a search of the environment with removal of means, and urgent communication with the treatment team. No-suicide contracts are not evidence-based and never replace observation and environmental safety.

Question 33Comprehensive Assessment and Care Planning

A genogram is used in a comprehensive psychiatric assessment primarily to:

  1. Determine the client's legal status for involuntary admission
  2. Record the client's medication adherence over time
  3. Map family relationships and patterns of illness across generations Correct answer.
  4. Measure the client's current level of cognitive impairment

Explanation

A genogram is a multigenerational diagram that maps family relationships and patterns of mental illness, substance use, and loss across at least three generations. It helps the nurse identify biological and environmental risk factors and plan family-centred care.

Question 34Comprehensive Assessment and Care Planning

A client with recurrent suicidal ideation is being discharged after a period of stabilization. Which element belongs in a collaborative safety plan?

  1. A schedule of weekly bloodwork to monitor medication levels
  2. Warning signs, coping strategies, and crisis contact numbers Correct answer.
  3. A signed agreement in which the client promises not to act on suicidal thoughts
  4. A list of the client's delusional beliefs for staff to review at follow-up

Explanation

A safety plan is written with the client and lists early warning signs, internal coping strategies, people and places that provide distraction, and contact details for supports and crisis services. It is a coping-focused plan rather than a promise or contract, and it is reviewed and updated with the client.

Question 35Comprehensive Assessment and Care Planning

An 82-year-old admitted for hip surgery becomes acutely confused, with fluctuating attention and visual hallucinations over the past 24 hours; before admission the client was alert and oriented. Which is the most likely explanation?

  1. Depression
  2. Delirium Correct answer.
  3. Dementia
  4. Mild cognitive impairment

Explanation

Acute onset, fluctuating attention, and visual hallucinations in the context of surgery and hospitalization are hallmarks of delirium, a medical emergency that requires identifying and treating the underlying cause, such as infection, pain, or withdrawal. Dementia is typically insidious and progressive, and depression produces a more stable picture without fluctuating attention.

Question 36Comprehensive Assessment and Care Planning

A client who speaks only Mandarin is admitted, and the client's adult child offers to interpret the initial assessment. What should the nurse do?

  1. Accept the offer, since family members know the client best
  2. Defer the assessment until a Mandarin-speaking nurse is on duty the next day
  3. Use written questions in Mandarin and have the client answer on paper
  4. Arrange a trained medical interpreter and speak directly to the client Correct answer.

Explanation

A trained medical interpreter protects accuracy and confidentiality and prevents the role conflict and possible editing that occur when a family member interprets sensitive information. The nurse should address the client directly and check that the message was understood, rather than deferring a needed assessment.

Question 37Comprehensive Assessment and Care Planning

A client with bipolar disorder refuses a prescribed mood stabilizer, saying, "I don't need it, the team just wants to control me." Before concluding that the client lacks capacity, the nurse should assess whether the client can:

  1. Name at least three side effects of the medication without prompting
  2. Agree with the treatment team's recommendation
  3. Recite the hospital's medication policy from memory
  4. Understand the information, appreciate its relevance, reason with it, and communicate a choice Correct answer.

Explanation

Capacity is decision-specific and rests on four abilities: understanding relevant information, appreciating how it applies to oneself, reasoning about options and consequences, and communicating a choice. Disagreement with the team, or an unusual explanation for it, is not by itself evidence of incapacity.

Question 38Comprehensive Assessment and Care Planning

A nurse is completing an admission history with a client who has post-traumatic stress disorder. Which approach best reflects trauma-informed assessment?

  1. Avoid asking any questions about the client's past so that no distress is caused during the admission
  2. Obtain a detailed chronological account of the trauma so that triggers can be documented in the care plan
  3. Ask the client to write out the trauma history and hand it in rather than speaking about it
  4. Explain each question's purpose, offer choices, and let the client limit the detail shared Correct answer.

Explanation

Trauma-informed care prioritizes safety, trustworthiness, choice, collaboration, and empowerment, so the nurse explains the purpose of questions and lets the client control how much to disclose. A detailed trauma narrative is not required for an admission assessment and can re-traumatize the client, while avoiding all history-taking leaves unmet needs unidentified.

Question 39Comprehensive Assessment and Care Planning

Four days after starting haloperidol, a client paces the unit, cannot sit still, and reports an uncomfortable inner restlessness, with no racing thoughts and no hallucinations. What is the most likely explanation and the nurse's best action?

  1. Tardive dyskinesia; stop all antipsychotics permanently and document the abnormal movements
  2. Worsening agitation from psychosis; recommend increasing the haloperidol dose tonight
  3. Akathisia; report the finding and request a medication review or adjunctive treatment Correct answer.
  4. Acute dystonia; give intramuscular benztropine and document the response in the chart

Explanation

Inner restlessness with pacing and an inability to sit still, beginning within days of a dopamine-blocking antipsychotic, is characteristic of akathisia. The nurse should report it, because it causes considerable distress and is linked to suicidal thinking, and the prescriber may reduce the dose, switch agents, or add a beta-blocker. Acute dystonia involves sustained muscle contraction, and tardive dyskinesia emerges later with involuntary orofacial movements.

Question 40Comprehensive Assessment and Care Planning

A 78-year-old presents with three months of worsening memory complaints, low mood, poor sleep, and appetite loss. On testing the client frequently answers "I don't know," gives up easily, and performs better when encouraged and given extra time. Which interpretation is most supported?

  1. The findings are typical of early Alzheimer's disease, since memory loss is the presenting complaint
  2. The client is malingering in order to avoid placement in a long-term care facility
  3. The pattern suggests depression with cognitive impairment and warrants treatment and reassessment Correct answer.
  4. The findings indicate delirium and require immediate transfer to an intensive care unit

Explanation

Effortful "I don't know" answers, giving up easily, and better performance with encouragement and extra time, combined with low mood, poor sleep, and appetite change, suggest depression with cognitive impairment rather than a progressive dementia. Treating the mood disorder and reassessing cognition after several weeks is appropriate, because reversible causes must be addressed first.

Question 41Comprehensive Assessment and Care Planning

During a mental status examination, which component reflects a client's awareness of having an illness and understanding of the need for treatment?

  1. Orientation
  2. Attention
  3. Insight Correct answer.
  4. Judgment

Explanation

Insight is the client's self-awareness of the illness and recognition that treatment may be needed. Judgment concerns decision-making and consequences, while orientation and attention are cognitive functions. Nurses document insight separately because it strongly influences engagement in care planning.

Question 42Comprehensive Assessment and Care Planning

A client admitted for a depressive episode reports new slurred speech and right-sided weakness. What is the nurse's priority action?

  1. Document the findings and reassess in four hours
  2. Explore whether the client is expressing emotional distress
  3. Activate emergency medical evaluation immediately Correct answer.
  4. Schedule a psychiatric reassessment for the next shift

Explanation

New focal neurological signs such as slurred speech and unilateral weakness suggest an acute neurological event, possibly stroke. These findings require urgent medical evaluation rather than observation or psychological exploration. Psychiatric admission does not remove the need for physical assessment.

Question 43Comprehensive Assessment and Care Planning

Which screening tool is used to measure the severity of depressive symptoms?

  1. GAD-7
  2. MMSE
  3. CAGE
  4. PHQ-9 Correct answer.

Explanation

The PHQ-9 scores the nine depressive symptom criteria and is widely used to grade severity and monitor response. The GAD-7 measures anxiety, the CAGE screens alcohol use, and the MMSE assesses cognition. Using the right tool supports accurate care planning.

Question 44Comprehensive Assessment and Care Planning

A client with bipolar disorder refuses a blood test required to monitor lithium. The client is calm, understands the information, and can explain the consequences. What should the nurse do first?

  1. Respect the refusal and document the client's decision Correct answer.
  2. Restrain the client and obtain the sample
  3. Ask the psychiatrist to certify the client involuntarily
  4. Proceed with the blood test because the client lacks capacity

Explanation

Capacity is presumed in Canadian law unless there are reasonable grounds to doubt it. A calm client who understands and can explain consequences demonstrates capacity for this decision. The nurse should respect the refusal, document the discussion, and continue to monitor safety.

Question 45Comprehensive Assessment and Care Planning

When completing a cultural assessment with a client from a different cultural background, which action is most appropriate?

  1. Explore the client's cultural explanation of the problem Correct answer.
  2. Rely on family members to explain cultural beliefs
  3. Avoid discussing culture to prevent discomfort
  4. Use identical questions for every client to ensure fairness

Explanation

Cultural assessment invites the client to explain how culture shapes their understanding, coping, and preferred care. Standardized questioning alone can miss important beliefs and practices. Family should not be used as a substitute for asking the client directly.

Question 46Comprehensive Assessment and Care Planning

In a biopsychosocial formulation, which term describes current stressors or events that triggered the present episode?

  1. Precipitating factors Correct answer.
  2. Predisposing factors
  3. Protective factors
  4. Perpetuating factors

Explanation

Precipitating factors are recent stressors or events that set off the current episode. Predisposing factors are longstanding vulnerabilities, perpetuating factors maintain the problem, and protective factors reduce risk. Distinguishing them helps target care planning.

Question 47Comprehensive Assessment and Care Planning

A client living alone after a first psychotic episode is being discharged. Which assessment finding most directly affects the safety of the discharge plan?

  1. No reliable access to prescribed antipsychotics Correct answer.
  2. The client prefers to take evening walks alone
  3. The client's mother has a history of hypertension
  4. The client completed high school many years ago

Explanation

Access to and ability to take prescribed antipsychotics is essential for preventing relapse after a first psychotic episode. Without reliable access, the discharge plan is unsafe regardless of other social preferences. The nurse should arrange medication supports before discharge.

Question 48Comprehensive Assessment and Care Planning

Which tool is designed to assess a client's ability to perform basic activities of daily living?

  1. CAGE
  2. Barthel Index Correct answer.
  3. GAD-7
  4. PHQ-9

Explanation

The Barthel Index measures independence in basic activities of daily living such as bathing, dressing, and mobility. The PHQ-9 and GAD-7 are symptom scales, and the CAGE screens alcohol use. Functional assessment informs safe care planning and discharge supports.

Question 49Comprehensive Assessment and Care Planning

A client with schizophrenia and a history of violence is pacing and muttering on the unit. Which action best reflects a trauma-informed, least-restrictive approach to prevent escalation?

  1. Place the client in seclusion before any violence occurs
  2. Administer a PRN antipsychotic without offering a choice
  3. Offer a quiet space and ask what would help Correct answer.
  4. Confront the client about muttering in the hallway

Explanation

A trauma-informed approach offers choice, reduces stimulation, and asks the client what would help them feel safer. Seclusion and forced medication are restrictive and should be used only when less restrictive measures fail and risk is imminent. Confrontation can escalate agitation.

Question 50Comprehensive Assessment and Care Planning

A client with anorexia nervosa has a heart rate of 48 beats/min and a potassium level of 2.9 mmol/L. Which action should the nurse take first?

  1. Provide psychoeducation about healthy eating
  2. Allow the client to continue refusing breakfast
  3. Discuss body image concerns in a therapy group
  4. Escalate for immediate medical assessment and cardiac monitoring Correct answer.

Explanation

Bradycardia and hypokalemia are potentially life-threatening complications of anorexia nervosa and require urgent medical assessment and cardiac monitoring. Psychotherapeutic work can continue once the client is medically stable. Physical stabilization takes priority in care planning.