Psych Exam 4

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Sample questions from Psych Exam 4

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 27-year-old client with a history of assault paces, clenches both fists, and shouts, "Get away from me!" The client is breathing rapidly; HR is 118/min and BP is 146/88 mm Hg. Which action should the nurse take first?

   • A.Tell the client that security will restrain them if they do not stop shouting
   • B.Stand close and ask the client to explain why the behavior is unreasonable
   • C.Approach slowly, keep a clear exit, and speak calmly from a respectful distance
   • D.Turn away and continue documenting until the client calms down

   Rationale: A calm voice, nonthreatening distance, and an unobstructed exit support safety while reducing stimulation. Challenging the client or threatening restraint can intensify escalation, and ignoring the behavior fails to assess immediate risk. The priority is to de-escalate and maintain safety, not to reason with a highly agitated client.

2. 2.Refer to the client's chart. Which actions should the nurse take now to reduce the risk of harm? Select all that apply.

   • A.Ask several staff members to surround the client
   • B.Tell the client that the nurse will not continue until the client apologizes
   • C.Use one staff member to speak in a calm, brief manner
   • D.Offer a quieter area and reduce unnecessary stimulation
   • E.Keep a clear route to the exit and maintain personal space

   Rationale: One calm speaker, respectful space, and reduced stimulation are appropriate because the client is pacing, clenching fists, and becoming louder. Surrounding the client may feel threatening, while requiring an apology is confrontational and does not address immediate safety. The rising HR and escalating behavior support prompt, least-restrictive de-escalation.

3. 3.During an evening shift on an adolescent psychiatric unit, a 16-year-old client says, "If he comes near me again, I'll hit him," while glaring at a peer across the room. The client has not moved toward the peer. What is the nurse's priority response?

   • A.Ask the peer to explain what caused the disagreement
   • B.Separate the clients safely and assess the client's intent, plan, and access to means
   • C.Wait to intervene until the client makes physical contact
   • D.Tell the client that threats are unacceptable and require an immediate apology

   Rationale: A specific threat requires immediate assessment of intent and steps to protect both clients, including safe separation. Demanding an apology or investigating the conflict first may escalate the situation, and waiting for contact risks injury. Address imminent safety before exploring the interpersonal dispute.

4. 4.At a community crisis center, a 41-year-old client who is shouting and pacing says, "I can't sit still; everybody is in my way." The client has not threatened anyone and accepts an offer to move to a quieter room. Which response best supports de-escalation?

   • A."Why are you acting this way when no one has hurt you?"
   • B."You need to calm down before I can help you."
   • C."If you keep pacing, you will lose your privileges."
   • D."Let's move to the quieter room together; I will give you space."

   Answer and rationale are in the full material.

5. 5.At change of shift in a behavioral health unit, a 35-year-old client with a history of assaults is increasingly loud, pacing near another client, and repeatedly balling both hands into fists. Which action should the nurse take first?

   • A.Direct staff to create space between the clients while one nurse calmly engages the client
   • B.Request that several staff members question the client about the pacing
   • C.Ask the other client to remain nearby and reassure the agitated client
   • D.Wait for the scheduled group to end before changing the environment

   Answer and rationale are in the full material.