15 free questions from the CinnaRN psychosocial integrity bank (299 in the app). Tap an answer to check it. The rationale opens right away.
A client with paranoid delusions believes the staff are poisoning their food and refuses to eat. Which response by the nurse is most therapeutic?
Answer: B. I understand you feel frightened. I can see no one has tampered with the food
The nurse neither argues with nor agrees with the delusion. Acknowledging the client's feeling (fear) while presenting reality non-confrontationally maintains trust and does not reinforce the false belief.
An older adult with Alzheimer disease becomes agitated and repeatedly tries to leave the unit in the late afternoon, pacing and calling for family. Which nursing approach is most appropriate?
Answer: C. Reduce stimulation, reassure the client, and redirect to a calm activity
This pattern of increased confusion and agitation in the late afternoon and evening is sundowning. Reducing environmental stimulation, providing reassurance, and redirecting the client to a calm, structured activity is the best first response. Restraints and confrontation increase agitation.
A client with Lewy body dementia experiences vivid visual hallucinations. Which nursing response is most therapeutic when the client is not in danger?
Answer: A. Remain calm, reassure safety, and avoid arguing about the hallucination
Visual hallucinations are a hallmark of Lewy body dementia. When the client is calm and safe, the nurse should remain calm, reassure the client of safety, and avoid arguing about whether the hallucination is real. Confronting or playing along inappropriately can increase distress.
A client from a culture that values stoicism denies pain verbally but grimaces and guards the surgical site. What is the nurse's best action?
Answer: A. Acknowledge the nonverbal cues and gently offer pain relief while respecting the client's expression
Cultural background affects how clients express pain. When verbal report and behavioral cues conflict, the nurse should explore the discrepancy sensitively, acknowledge behavioral signs, and offer pain relief rather than simply accepting the denial at face value.
A client in the depressive phase of bipolar disorder remains in bed, avoids interaction, and shows poor hygiene. Which nursing intervention is appropriate?
Answer: B. Spend brief, regular time with the client and assist with hygiene
For a severely depressed client, the nurse should spend time with the client and provide structured, simple activities and assistance with hygiene, building a trusting relationship without overwhelming demands. Forcing immediate cheerful socializing or withholding attention is non-therapeutic.
A client with dementia begins to cry and reaches out repeatedly to a doll, holding it like a baby. Which nursing response is most appropriate?
Answer: A. Allow the client to keep the doll and observe for comfort
Doll or stuffed-animal therapy can provide comfort and reduce distress in some clients with dementia; allowing the behavior and observing for comfort is appropriate and nonjudgmental. Removing the doll, scolding, or insisting on reality orientation increases distress.
A nurse photographs a client's surgical wound on a personal phone to show a friend, without the client's permission. Which client right has the nurse violated?
Answer: B. The right to privacy and confidentiality
Taking and sharing images of a client without consent violates the client's right to privacy and confidentiality of protected health information. Photographing clients on personal devices breaches HIPAA and facility policy. Any clinical photography requires consent and use of approved, secure systems.
A client says, "I don't want my family to know how sick I really am." Which response best respects the client and explores the concern?
Answer: B. "You'd prefer they not know the details. Can you tell me your concerns?"
An exploratory, nonjudgmental response ("You'd prefer they not know the details; can you tell me your concerns?") respects autonomy and explores reasons. Pressuring disclosure, judging, or promising secrecy the nurse cannot keep are inappropriate.
A client with schizophrenia tells the nurse, "I feel safe nowhere; the FBI watches me through the television." Which is the most therapeutic response?
Answer: B. "It sounds like you are feeling frightened and unsafe right now."
Reflecting the feeling beneath the delusion, fear and lack of safety, is therapeutic because it focuses on the client's emotion rather than debating the false belief. Responding to the underlying feeling helps the client feel understood and builds trust. Agreeing with the delusion reinforces it, disproving it by examining the TV is non-therapeutic, and abruptly changing the subject dismisses the client's distress.
A nurse believes a provider's prescription is unsafe for a client. Which action best demonstrates the nurse's role as a client advocate?
Answer: B. Clarify the concern with the prescriber before carrying out the order
Client advocacy and safe practice require the nurse to question any prescription that appears unsafe and to clarify it with the prescriber before carrying it out. If concerns remain, the nurse follows the chain of command. The nurse is legally accountable and should not administer a clearly unsafe order simply because it was written.
A client recovering from substance use disorder is being discharged. Which statement indicates the client has a realistic understanding of recovery?
Answer: A. "I will attend support meetings and have a relapse-prevention plan."
Recovery is an ongoing process, and relapse is a risk that requires a plan, support systems, and continued engagement (for example, a 12-step program or counseling). Recognizing the need for ongoing support and a relapse-prevention plan shows realistic insight. Believing one is permanently cured, that willpower alone is enough, or that occasional use is safe all reflect poor insight and high relapse risk.
A client 3 weeks postpartum reports persistent sadness, loss of interest in the baby, difficulty sleeping even when the baby sleeps, and feelings of worthlessness. What does the nurse recognize?
Answer: A. Postpartum depression requiring referral
Symptoms persisting beyond 2 weeks with loss of interest, sleep disturbance unrelated to the infant, and feelings of worthlessness indicate postpartum depression rather than transient baby blues. It requires referral and treatment. Baby blues resolve within about 2 weeks.
A young client newly paralyzed from a spinal cord injury says, "I am useless now and will never matter to anyone." Which response by the nurse is most therapeutic?
Answer: A. "This is a major change. Tell me more about what you are feeling."
Acknowledging the client's feelings and encouraging expression conveys empathy and supports adjustment to a major loss; grief and adjustment are expected after spinal cord injury. False reassurance, changing the subject, or minimizing the loss shuts down communication and dismisses the client's feelings.
During a de-escalation attempt, an agitated client says, You people never listen to me! Which response best reflects active listening?
Answer: B. I hear that you feel unheard. Help me understand what you need
Reflecting and validating the client's experience (I hear that you feel unheard) demonstrates empathy and lowers defensiveness, opening the door to collaborative problem-solving. Defending the staff or dismissing the complaint escalates anger.
A client recovering from a stroke becomes tearful and laughs uncontrollably at inappropriate times. The family is distressed. What is the nurse's best response?
Answer: B. Explain that emotional lability is a common effect of stroke and reassure the family
Emotional lability (pseudobulbar affect) is common after stroke and reflects brain injury, not the client's true feelings or psychiatric illness. Reassuring the family that this is a recognized effect of the stroke and teaching them to remain calm is appropriate.
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