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National Council Licensure Examination(NCLEX-PN) Questions 311–315 (page: 64)

Updated On: 9-Feb-2026

A 14-year-old boy has been admitted to a mental health unit for observation and treatment. The boy becomes agitated and starts yelling at nursing staff members.

What should the nurse first response be?

  1. Create an atmosphere of seclusion for the boy according to procedures.
  2. Remove other patients from the area via wheelchairs for added speed.
  3. Ask the patient, “What is making you mad?”
  4. Ask the patient, “Why are you doing this, have you thought about what your parents might say?”

Answer(s): A

Explanation:

Seclusion is your best option in this scenario.



A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?

  1. Check with case manager on duty about possible police intervention.
  2. Provide an environment of concern and emotional stabilization.
  3. Clean the patient’s wounds with normal saline and gauze.
  4. Recommend a good attorney to the patient.

Answer(s): B

Explanation:

Emotional support is what that patient needs most at this point in time.



A two-year old has been in the hospital for 3 weeks and seldom seen family members due to isolation precautions.

Which of the following hospitalization changes is most like to be occurring?

  1. Guilt
  2. Trust
  3. Separation anxiety
  4. Shame

Answer(s): C

Explanation:

Separation anxiety can easily occur after six months during hospitalization.



If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?

  1. Conveying calmness with one on one interaction.
  2. Recognizing and dealing with your own feelings to prevent escalation of the patient’s anxiety level.
  3. Encourage client participation in group therapy.
  4. Listen and identify causes of their behavior.

Answer(s): C

Explanation:

Acutely psychotic patients will disrupt group activities.



A nurse runs into the significant other of a patient with end stage AIDS crying during her smoke break. Which of the following is most appropriate action for the nurse to take?

  1. Allow her to grieve by herself.
  2. Tell her go ahead and cry, after all your husband’s pretty bad off.
  3. Tell her you realize how upset she is, but you don’t want to talk about it now.
  4. Approach her, offering tissues and encourage her to verbalize her feelings.

Answer(s): D

Explanation:

Being left alone during the grief process, isolates individuals.
These individuals need an outlet for their feelings and to talk to someone who is empathetic.



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