During a one-to-one talk a client with schizophrenia tells the nurse, 'I am going to hurt my neighbor tonight when she gets home. Don't tell anyone, you promised to keep what I say private.' Which action by the nurse is correct?
Respect the request for confidentiality and increase one-to-one time with the client until his mood settles and the threat passes
Ask the client to promise that he will not act on the threat and document his promise in the chart
Encourage the client to warn the neighbor himself and document that he agreed to do so
Tell the client that privacy has limits, then report the threat right away to the provider and charge nurse
Show the answer and explanation
Answer: D. Tell the client that privacy has limits, then report the threat right away to the provider and charge nurse
Topic: duty to protect an identifiable victim
Confidentiality has limits when a client makes a serious threat against an identifiable person. The nurse tells the client honestly that the information cannot be kept private and reports it at once so the team can protect the neighbor and notify the right parties as law and policy require. Handling the threat alone or relying on the client's promise leaves the person at risk.
Why the others are wrong
A – Keeping the threat private leaves the neighbor unprotected and breaks the duty to report.
B – A promise from a client who is acutely ill does not make the neighbor safe, and the team still has not been told.
C – Warning the victim is a legal and team responsibility, not a task for the client who made the threat.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
2Question
A client with acute mania repeatedly walks into other clients' rooms uninvited, takes their snacks and makes sexual remarks to peers. Which response by the nurse is best?
Overlook the behavior, because it is a symptom of the illness and will pass once the medication takes effect
State calmly and briefly that the behavior is not acceptable, then redirect the client to a quiet activity
Explain in detail how the behavior affects the other clients and ask the client to think about it
Place the client in seclusion for the rest of the shift so that the behavior has a consequence
Show the answer and explanation
Answer: B. State calmly and briefly that the behavior is not acceptable, then redirect the client to a quiet activity
Topic: limit setting in mania
A client in mania has poor impulse control and cannot reflect on long explanations. The nurse sets clear, brief, consistent limits in a calm voice and redirects the client to a low-stimulation activity. Limits protect the other clients and the client's dignity without punishment.
Why the others are wrong
A – Ignoring the behavior leaves other clients exposed and does not teach limits.
C – A client in mania cannot attend to long explanations, which are also stimulating.
D – Seclusion as punishment is not the least restrictive option and is not allowed as a consequence.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
3Question
A client who was placed in seclusion for 40 minutes after striking a peer is now calm and has been released from the seclusion room. Which nursing action is most important next?
Review the event with the client, including what led up to it, how it felt and what could be done differently next time
Withhold the client's privileges for 24 hours to reinforce that the behavior was unacceptable
Wait until discharge planning to discuss the event so that the client is not upset again
Document the event and move on, since discussing it may bring back the agitation
Show the answer and explanation
Answer: A. Review the event with the client, including what led up to it, how it felt and what could be done differently next time
Topic: debriefing after seclusion
After seclusion or restraint, a debriefing with the client as soon as it is safe helps the client understand the event, identify triggers and plan alternatives. The staff also review what happened to prevent repeats, and the client's account is part of the record. Punishment or silence leaves the trauma and the triggers unaddressed.
Why the others are wrong
B – Withholding privileges is punitive and does not help the client avoid the behavior.
C – Waiting until discharge wastes the chance to review triggers while the event is fresh.
D – Documentation is required, but silence leaves the client's experience and triggers unaddressed.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
4Question
An older client with delirium keeps pulling at an IV line and a urinary catheter. Before requesting a restraint order, which interventions should the nurse try?
Select all that apply.
Apply a vest restraint right away so that he cannot reach the lines
Ask a family member or sitter to stay with him
Cover the IV site with a sleeve or dressing and remove devices that are no longer needed
Give a sedative as needed to keep him quiet before looking for the cause
Look for causes such as pain, a full bladder, low oxygen or a medication effect
Provide glasses and hearing aids and reorient him to time and place
Show the answers and explanation
Answers: B, C, E and F.
B – Ask a family member or sitter to stay with him
C – Cover the IV site with a sleeve or dressing and remove devices that are no longer needed
E – Look for causes such as pain, a full bladder, low oxygen or a medication effect
F – Provide glasses and hearing aids and reorient him to time and place
Topic: alternatives to restraint in delirium
Restraint is a last resort and is used only when less restrictive measures have failed. For a client with delirium the nurse looks for and treats causes, uses supports such as a sitter or family, hides or removes lines and devices, and supports orientation with sensory aids. Sedatives and early restraint treat the behavior and not the cause and increase risk.
Why the others are wrong
A – A vest restraint is a more restrictive measure and may worsen delirium and agitation; less restrictive options come first.
D – Sedating a delirious client without looking for the cause can worsen confusion and increase fall and aspiration risk.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
5Question
A client with moderate Alzheimer disease becomes tearful, shouts and strikes out in the dining room after being asked to complete a puzzle. Which interventions should the nurse use?
Select all that apply.
Remind the client firmly of the date, the place and what he is supposed to do
Remain calm and speak slowly in a soft voice
Apply wrist restraints until the client settles
Move the client to a quiet area with fewer people and less noise
Insist that the client finish the puzzle so that he does not give up
Ask the client several questions about why he became upset
Show the answers and explanation
Answers: B and D.
B – Remain calm and speak slowly in a soft voice
D – Move the client to a quiet area with fewer people and less noise
Topic: catastrophic reaction in dementia
This is a catastrophic reaction, an exaggerated response when demands exceed the abilities of a client with dementia. The nurse reduces demands and stimulation, stays calm, moves the client to a quiet place and later offers a simpler familiar activity. Pressing, quizzing or restraining the client increases distress.
Why the others are wrong
A – Firm reorientation adds pressure and the client cannot use the information.
C – Restraints increase fear and agitation and are not an acceptable first response.
E – Insisting increases the overload that caused the reaction.
F – The client cannot explain the reason and questions add demand.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
6Question
A client on an inpatient psychiatric unit is pacing the hallway, clenching both fists and shouting at peers. The client has a history of assaulting staff. Which actions should the nurse take when approaching this client?
Select all that apply.
Use a calm, low voice and short, clear sentences
Keep a safe distance and stay positioned with a clear path to the exit
Stand directly in front of the client to block the hallway
Maintain constant, intense eye contact to show authority
Acknowledge the client's feelings and listen without arguing
Touch the client's shoulder to offer reassurance
Show the answers and explanation
Answers: A, B and E.
A – Use a calm, low voice and short, clear sentences
B – Keep a safe distance and stay positioned with a clear path to the exit
E – Acknowledge the client's feelings and listen without arguing
Topic: de-escalating an agitated client
De-escalation relies on a calm presence, respectful space and genuine listening. A low, steady voice and short sentences lower stimulation, a safe distance with an exit protects both client and nurse, and acknowledging feelings helps the client feel heard. Blocking, staring and unwanted touch can be perceived as threats and escalate the situation.
Why the others are wrong
C – Blocking the hallway makes the client feel cornered and increases the risk of assault.
D – Constant intense eye contact can be seen as a challenge and may provoke aggression.
F – Touching an agitated, possibly paranoid client without permission can be perceived as an attack.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
7Question
A nurse records a school-age child's outburst. Just before it, the teacher took away a tablet; the child then screamed and threw a pencil; the teacher then excused the child from the assignment. In this behavioral assessment, which entry is the consequence?
The teacher took away the tablet
The child screamed and threw a pencil across the classroom
The child's age and grade level
The teacher excused the child from the assignment
Show the answer and explanation
Answer: D. The teacher excused the child from the assignment
Topic: antecedent-behavior-consequence
A behavioral analysis records the antecedent (what came before), the behavior, and the consequence (what followed). Here the child escaped the task after the outburst, which may reinforce the behavior.
Why the others are wrong
A – Removing the tablet happened before the outburst, so it is the antecedent.
B – Screaming and throwing a pencil is the behavior itself.
C – Age and grade are background information, not events in the sequence.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
NCLEX-RN is a registered trademark of the National Council of State Boards of Nursing, Inc. (NCSBN). This site is not affiliated with, sponsored by or endorsed by the owner of that mark.
Nursing