What is the most appropriate nursing action when t

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Question 1 of 5

What is the most appropriate nursing action when the terminally ill client's death is imminent?

A. Stay with the client and contact the family. B. Notify the hospital chaplain of the potential for death. C. Call the funeral home, alerting them of an imminent death. D. Transfer the client to the intensive care unit.

Correct Answer: A

Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.

Question 2 of 5

The client has been placed in restraints for violent behavior. Which statement best indicates the nurse’s understanding of the risk for client injury while being restrained?

A. “Can you arrange to order the client’s favorite sandwich for his lunch?” B. “I need to make sure the restraints’ release mechanisms are working properly.” C. “I need someone to continuous monitor the client and relieve me for a few minutes.” D. “The client’s feet feel a little cool but they have a good pulse. I’ll get a pair of socks.”

Correct Answer: C

Rationale: Continuous monitoring (
C) prevents injury during restraint. Nutrition (
A) release mechanisms (
B) and circulation checks (
D) are secondary to constant observation.

Question 3 of 5

The client with a history of aggressive behavior toward staff and peers states to the nurse “Everyone is just so touchy; I don’t see where I’m being too aggressive.” Which nursing action should be included in the therapeutic plan of care to best effect a difference in perceptions?

A. Refamiliarize the client with the rules of the unit. B. Introduce nonaggressive interpersonal behaviors to the client. C. Promote dialogue between the staff and client to discuss the staff’s perceptions of aggressive behavior. D. Encourage the staff to show patience to the client because the client may have poor aggression control.

Correct Answer: C

Rationale: Dialogue (
C) clarifies differing perceptions of aggression. Rules (
A) or behaviors (
B) are less effective without addressing perceptions and patience (
D) risks safety.

Question 4 of 5

The client who sustained a brain injury from an MVA is now experiencing aggression impulsivity and poor judgment. In teaching the family which area of the brain illustrated should the nurse identify as being affected?

A. Line A B. Line B C. Line C D. Line D

Correct Answer: B

Rationale: The prefrontal cortex (Line
B) modulates judgment aggression and impulsivity. Cortex (
A) controls motor functions hypothalamus (
C) regulates temperature/fluids and cerebellum (
D) manages balance. image4.png

Question 5 of 5

The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?

A. Allow the parent to enter the room and see the child. B. Tell the parent that the HCP wants to speak with the parent first. C. Contact Social Services to report the parent’s abusive behavior. D. Initiate the emergency response system for behavioral situations.

Correct Answer: D

Rationale: Initiating the emergency response (
D) ensures safety. Allowing entry (
A) deferring to HCP (
B) or reporting to Social Services (C likely already done) are inappropriate.

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Mental Health NCLEX Questions with Rationale Questions

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