Question

The client tells the nurse, "My biggest problem right now is trying to deal with a divorce. I didn't want a divorce and I still don't. But it is happening anyway!" Which of the following responses by the nurse would be the best example of empathy?

Answer 1

Correct Answers:

"I can't imagine how difficult this must be for you."

Rationale :

🌹 "I can't imagine how difficult this must be for you" is the best example of empathy because the nurse is acknowledging the client's emotional pain without making assumptions about the experience.

🌹 Empathy involves recognizing, understanding, and validating another person’s feelings while maintaining professional boundaries.

🌹 The statement communicates acceptance, support, and willingness to understand the client’s perspective during a stressful life event.

🌹 The nurse does not minimize the client’s distress or attempt to immediately fix the problem.

🌹 Divorce can involve feelings of loss, grief, fear, anger, and uncertainty, and the nurse should first acknowledge these emotions.

🌹 Therapeutic communication requires the nurse to focus on the client’s feelings rather than providing statistics, advice, or reassurance.

🌹 This response encourages the client to continue expressing concerns and promotes a trusting nurse-client relationship.

🌹 Therefore, the most empathetic response is “I can't imagine how difficult this must be for you.”

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Answer 2

Correct Answers:

"You've already done it once. With continued practice, you'll become comfortable managing this."

Rationale :

🌻 "You've already done it once. With continued practice, you'll become comfortable managing this" is the best response because it promotes self-efficacy, which is the client’s belief in their ability to successfully perform a task.

🌻 The nurse is reinforcing the client’s previous success by reminding them that they have already demonstrated the ability to administer insulin.

🌻 Positive reinforcement helps increase confidence and encourages the client to continue practicing the skill independently.

🌻 Learning self-insulin administration requires repeated practice, and anxiety is common when clients first learn a new health-management skill.

🌻 The nurse supports independence by focusing on the client’s ability rather than taking over the task.

🌻 Encouraging mastery through practice improves the client’s confidence and likelihood of long-term adherence to diabetes management.

🌻 This response acknowledges the client’s fear while providing realistic encouragement and support.

🌻 Therefore, the best response is “You've already done it once. With continued practice, you'll become comfortable managing this.”

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Answer 3

Correct Answers:

To return the client to their pre-crisis level of functioning

Rationale :

🌼 Returning the client to their pre-crisis level of functioning is the primary goal of crisis intervention because the immediate focus is helping the client regain stability and emotional balance.

🌼 A crisis occurs when a person experiences an overwhelming event or situation that exceeds their usual coping abilities.

🌼 Crisis intervention is a short-term therapeutic approach designed to restore the client’s ability to function and manage the current situation.

🌼 The nurse focuses on stabilization, safety, emotional support, and restoring effective coping mechanisms during the crisis period.

🌼 The goal is not to completely resolve all underlying life problems but to help the client return to their previous functional state.

🌼 Once stability is restored, the client may then explore long-term coping strategies, personal growth, or unresolved issues through continued therapy.

🌼 This approach prevents further deterioration and reduces the risk of harmful behaviors during periods of emotional distress.

🌼 Therefore, the primary goal of crisis intervention is to return the client to their pre-crisis level of functioning.

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Answer 4

Correct Answers:

Projection

Rationale :

🧿 Projection is the correct answer because the client is attributing his own unacceptable feelings of frustration, anger, or helplessness to another person.

🧿 The client is upset about his inability to ambulate, but instead of expressing his feelings about his own limitations, he directs the negative emotions toward the nurses.

🧿 Projection occurs when a person unconsciously transfers their own thoughts, feelings, or behaviors onto someone else.

🧿 In this situation, the client may feel dependent, powerless, or embarrassed, but he protects himself by accusing the nurses of being “lazy and incompetent.”

🧿 The nurse should recognize that the anger may be related to the client’s loss of independence rather than the actual performance of the healthcare team.

🧿 Therapeutic communication, emotional support, and helping the client regain a sense of control can help address the underlying frustration.

🧿 Recognizing defense mechanisms allows the nurse to respond professionally rather than becoming defensive or taking the statement personally.

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Answer 5

Correct Answers:

Mental health care in the least-restrictive setting possible

Rationale :

🌸 Mental health care in the least-restrictive setting possible is correct because outpatient day hospital programs allow clients to receive continued treatment while maintaining more independence than inpatient hospitalization.

🌸 The principle of least restrictive care means providing the safest and most effective treatment environment while limiting restrictions on the client’s freedom and daily life.

🌸 After a period of inpatient stabilization, many clients no longer require 24-hour hospital care but still need structured therapy, medication management, and monitoring.

🌸 A day hospital program provides an intermediate level of care between inpatient hospitalization and fully independent community living.

🌸 This approach supports reintegration into the community, promotes independence, and reduces unnecessary hospitalization.

🌸 The client can practice coping skills and daily functioning while still having access to mental health professionals.

🌸 This model reflects modern psychiatric care that emphasizes recovery, autonomy, and community support.

🌸 Therefore, the best explanation is that the client is receiving care in the least-restrictive setting possible.

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Answer 6

Correct Answers:

Benzodiazepine

Rationale :

💎 Benzodiazepines are the correct answer because they provide rapid relief of acute anxiety symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain.

💎 The client is experiencing acute anxiety following a traumatic event involving a parent’s automobile crash, requiring a medication with a fast onset of action.

💎 Benzodiazepines such as lorazepam or alprazolam can quickly decrease symptoms including severe worry, agitation, restlessness, and physiological anxiety responses.

💎 These medications are commonly used for short-term management of acute anxiety or panic symptoms, especially during crisis situations.

💎 The nurse should monitor for adverse effects such as sedation, respiratory depression, dizziness, and impaired coordination.

💎 Long-term use is avoided because benzodiazepines can cause tolerance, dependence, and withdrawal symptoms.

💎 SSRIs and other long-term medications may be useful for chronic anxiety disorders but do not provide immediate symptom relief.

💎 Therefore, the most effective medication for this client’s immediate acute anxiety is a benzodiazepine.

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Answer 7

Correct Answers:

Ensure the client has warm clothing and a heated environment.

Rationale :

🌻 Ensuring warmth and a heated environment is the priority because hypothermia threatens the client’s basic physiological needs, which are the lowest and most urgent level of Maslow’s Hierarchy of Needs.

🌻 According to Maslow, physiological needs such as body temperature regulation, oxygen, food, water, and shelter must be addressed before higher-level needs can be considered.

🌻 A homeless client with hypothermia has an immediate risk of cold-related injury, impaired circulation, altered mental status, cardiac dysrhythmias, and death.

🌻 Providing warm clothing and a heated environment helps restore the client’s core body temperature and prevents further heat loss.

🌻 The nurse should prioritize interventions that stabilize the client’s physical condition before addressing emotional, social, or financial concerns.

🌻 Once the client’s temperature is stabilized, the nurse can address additional needs such as counseling, healthcare access, and community resources.

🌻 Prioritizing physiological needs reflects safe nursing practice and follows Maslow’s framework for determining the order of care.

🌻 Therefore, the nurse should first provide warmth and a heated environment.

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Answer 8

Correct Answers:

"You feel fine now because the medication is helping. Let's talk about ways to make it easier to remember to take it."

Rationale :

✳️ This response best promotes medication compliance because it uses therapeutic communication, positive reinforcement, and patient-centered education rather than forcing the client to take the medication.

✳️ The nurse recognizes that the client’s improvement may actually be a result of the antidepressant working effectively, not because the medication is no longer needed.

✳️ Antidepressants often require consistent daily use to maintain therapeutic effects and prevent relapse of depressive symptoms.

✳️ Abruptly stopping antidepressants can lead to return of symptoms, withdrawal effects, or worsening depression, depending on the medication.

✳️ By discussing strategies to remember medications, the nurse helps the client overcome barriers and improves the likelihood of long-term adherence.

✳️ The response validates the client’s concern while providing education about the importance of continuing treatment.

✳️ Collaborative communication increases the client’s sense of control and promotes participation in their own care.

✳️ Therefore, the best response is to explain that the medication is helping and work with the client on ways to maintain adherence.

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Answer 9

Correct Answers

Self-care activities [ Indicated ]
Maintain therapeutic milieu [ Indicated ]
Administer medications [ Indicated ]
Prescribe medications [ Contraindicated ]
Psychotherapy [ Contraindicated ]

Rationale :

Self-care activities — Indicated

🖊️ Psychiatric RNs are responsible for helping clients improve activities of daily living (ADLs), especially when mental illness affects hygiene, nutrition, and personal care.

🖊️ This client demonstrates impaired self-care through poor hygiene, strong body odor, decreased appetite, and staying in bed all day due to severe depression.

🖊️ The nurse can encourage showering, provide clean clothing, and support gradual participation in self-care activities.

Maintain therapeutic milieu — Indicated

🖊️ Maintaining a therapeutic milieu is within the RN scope because psychiatric nurses create a safe, structured, and supportive environment for clients.

🖊️ The nurse monitors safety risks, establishes boundaries, promotes communication, and encourages participation in therapeutic activities.

🖊️ This client’s care plan includes monitoring for hazards and encouraging group therapy, which are nursing responsibilities.

Administer medications — Indicated

🖊️ Medication administration is within the scope of practice for an RN when medications are prescribed by an authorized provider.

🖊️ This client stopped taking medications for 5 months after losing employment, which may have contributed to worsening depressive symptoms.

🖊️ The nurse administers medications, monitors effectiveness, and observes for adverse effects or safety concerns.

Prescribe medications — Contraindicated

🖊️ Prescribing medications is outside the scope of practice for a psychiatric RN.

🖊️ Medication prescribing is performed by authorized providers such as psychiatrists, nurse practitioners with prescribing authority, or physicians according to regulations.

🖊️ The RN may administer and evaluate medications but does not independently order them.

Psychotherapy — Contraindicated

🖊️ Formal psychotherapy is not within the independent scope of a psychiatric nurse generalist RN.

🖊️ Psychotherapy is typically provided by qualified mental health professionals such as psychiatrists, psychologists, or licensed therapists.

🖊️ The RN may provide therapeutic communication, emotional support, and reinforce prescribed therapy plans, but does not conduct formal psychotherapy.

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Answer 10

Correct Answers:

Taking precautions to prevent suicide

Rationale :

🌼 Taking precautions to prevent suicide is the priority because the client has suicidal ideation, which represents an immediate threat to safety and survival.

🌼 According to Maslow’s Hierarchy of Needs, protection from harm and maintaining safety take priority over nutritional needs, medication adjustments, or weight restoration.

🌼 A client with major depressive disorder who expresses suicidal thoughts requires immediate assessment of suicide risk, including intent, plan, means, and level of supervision needed.

🌼 Antidepressants often require several weeks (commonly 4–6 weeks) before full therapeutic effects are seen, so lack of improvement after only one week is expected.

🌼 The nurse should implement suicide precautions, remove potential hazards, provide a safe environment, and closely monitor the client.

🌼 Preventing self-harm is the most urgent nursing priority because suicide can result in death if immediate safety measures are not taken.

🌼 Nutritional support and medication evaluation are important but can be addressed after the client’s immediate safety is ensured.

🌼 Therefore, the priority client problem is taking precautions to prevent suicide.

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Potential task	Indicated	Contraindicated
Self-care activities
Maintain therapeutic milieu
Administer medications
Prescribe medications
Psychotherapy

NUR175 Exam 1 Summer 2026 ABSN

No.

1 :
The client tells the nurse, "My biggest problem right now is trying to deal with a divorce. I didn't want a divorce and I still don't. But it is happening anyway!" Which of the following responses by the nurse would be the best example of empathy?

2 :
A nurse is teaching a newly diagnosed diabetic client how to self-administer insulin. The client practices once, then says, "I'm afraid I'll never get this right." Which of the following responses by the nurse best supports the client's self-efficacy?

3 :
The mental health unit received a new client who is experiencing a mental health crisis. The mental health nurse assesses the client, analyzes data, and then develops a plan of care and desired outcomes. What is the primary goal of crisis intervention?

4 :
A client who is frustrated with his inability to ambulate yells, "You nurses are lazy and incompetent!" The client's behavior is an example of which defense mechanism?

5 :
A mental health client was treated inpatient for one week and then discharged to an outpatient day hospital program for follow-up treatment. What is the best way to explain the reason for this type of treatment?

6 :
A client in the emergency department is experiencing acute anxiety related to their parent being in an automobile crash two hours earlier. Which of the following medications would be the most effective to administer at this time?

7 :
A nurse is caring for a homeless client who is admitted with hypothermia. According to Maslow's Hierarchy of Needs, which intervention should the nurse prioritize?

8 :
A nurse is conducting a discharge teaching session for a client who has been prescribed a new antidepressant medication. The client says, "I don't like taking pills every day. I feel fine, so I don't see the point." Which response by the nurse best promotes medication compliance?

9 :
A nurse at a mental health facility is taking care of a client.

Correct Answers

10 :
A newly admitted client diagnosed with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The client has taken an antidepressant medication for one week without remission of symptoms. Which is the priority client problem?

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NUR175 Exam 1 Summer 2026 ABSN

No.

1 : The client tells the nurse, "My biggest problem right now is trying to deal with a divorce. I didn't want a divorce and I still don't. But it is happening anyway!" Which of the following responses by the nurse would be the best example of empathy?

2 : A nurse is teaching a newly diagnosed diabetic client how to self-administer insulin. The client practices once, then says, "I'm afraid I'll never get this right." Which of the following responses by the nurse best supports the client's self-efficacy?

3 : The mental health unit received a new client who is experiencing a mental health crisis. The mental health nurse assesses the client, analyzes data, and then develops a plan of care and desired outcomes. What is the primary goal of crisis intervention?

4 : A client who is frustrated with his inability to ambulate yells, "You nurses are lazy and incompetent!" The client's behavior is an example of which defense mechanism?

5 : A mental health client was treated inpatient for one week and then discharged to an outpatient day hospital program for follow-up treatment. What is the best way to explain the reason for this type of treatment?

6 : A client in the emergency department is experiencing acute anxiety related to their parent being in an automobile crash two hours earlier. Which of the following medications would be the most effective to administer at this time?

7 : A nurse is caring for a homeless client who is admitted with hypothermia. According to Maslow's Hierarchy of Needs, which intervention should the nurse prioritize?

8 : A nurse is conducting a discharge teaching session for a client who has been prescribed a new antidepressant medication. The client says, "I don't like taking pills every day. I feel fine, so I don't see the point." Which response by the nurse best promotes medication compliance?

9 : A nurse at a mental health facility is taking care of a client.

Correct Answers

10 : A newly admitted client diagnosed with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The client has taken an antidepressant medication for one week without remission of symptoms. Which is the priority client problem?

1 :
The client tells the nurse, "My biggest problem right now is trying to deal with a divorce. I didn't want a divorce and I still don't. But it is happening anyway!" Which of the following responses by the nurse would be the best example of empathy?

2 :
A nurse is teaching a newly diagnosed diabetic client how to self-administer insulin. The client practices once, then says, "I'm afraid I'll never get this right." Which of the following responses by the nurse best supports the client's self-efficacy?

3 :
The mental health unit received a new client who is experiencing a mental health crisis. The mental health nurse assesses the client, analyzes data, and then develops a plan of care and desired outcomes. What is the primary goal of crisis intervention?

4 :
A client who is frustrated with his inability to ambulate yells, "You nurses are lazy and incompetent!" The client's behavior is an example of which defense mechanism?

5 :
A mental health client was treated inpatient for one week and then discharged to an outpatient day hospital program for follow-up treatment. What is the best way to explain the reason for this type of treatment?

6 :
A client in the emergency department is experiencing acute anxiety related to their parent being in an automobile crash two hours earlier. Which of the following medications would be the most effective to administer at this time?

7 :
A nurse is caring for a homeless client who is admitted with hypothermia. According to Maslow's Hierarchy of Needs, which intervention should the nurse prioritize?

8 :
A nurse is conducting a discharge teaching session for a client who has been prescribed a new antidepressant medication. The client says, "I don't like taking pills every day. I feel fine, so I don't see the point." Which response by the nurse best promotes medication compliance?

9 :
A nurse at a mental health facility is taking care of a client.

10 :
A newly admitted client diagnosed with major depressive disorder has lost 20 pounds over the past month and has suicidal ideation. The client has taken an antidepressant medication for one week without remission of symptoms. Which is the priority client problem?