WITH VERIFIED ANSWERS 2025/2026
D. There is no gate. - CORRECT ANSWER A charge nurse overhears another nurse
talking with a client who has schizophrenia. Suddenly the client yells, "I am the
devil, I am God. Open the gate for me!" What following replies by the nurse
requires intervention by the charge nurse?
A. Tell me who you are I don't understand.
B. Can you tell me what that means?
C. Are you saying that you are both good and bad?
D. There is no gate.
A. Is a danger to herself or others - CORRECT ANSWER A nurse in a psychiatric unit
is caring for a client who is being admitted involuntarily after attacking a neighbor.
The nurse knows that the client can be kept on the 72 hour hold is over if the
client
A. Is a danger to herself or others
B. Is unwilling to accept that treatment is needed
C. Does not have anyone that she could stay with
D. Is financially incapable of paying for prescription medications
A. Neuroleptic malignant syndrome (NMS) - CORRECT ANSWER A nurse in the ED
is caring for a client taking Haldol for the past 3 months. The client's temperature
,is 102 F, BP 150/110, and has tachycardia. The nurse should know that these
indicate a diagnosis of Agranulocytosis
A. Neuroleptic malignant syndrome (NMS)
B. Hypertensive crisis
C. Tardive dyskinesia
D. Tell me more about your feelings about what happened to your wife. -
CORRECT ANSWER A nurse is admitting a client who has multiple trauma after a
motor vehicle accident. Shortly after admission, her husband arrives. He is
distraught and blames himself for the accident. Which of the following is an
appropriate nursing response?
A. Don't worry about that. Your wife will be fine.
B. I think you should calm down a little before you see your wife.
C. Why do you think the accident was your fault?
D. Tell me more about your feelings about what happened to your wife.
D. Early symptoms of tardive dyskinesia (TD) - CORRECT ANSWER A nurse is
assessing a client receiving treatment for schizophrenia with the typical
antipsychotic fluphenazine (prolix in) for 12 months. The nurse observes fine,
fasciculation tongue movements and associates this finding with which of the
following?
A. A drug food reaction to grapefruit juice
B. The client has missed several doses of medication
,C. Early symptoms of neuroleptic malignant syndrome (NMS)
D. Early symptoms of tardive dyskinesia (TD)
C. If I eat one piece of candy, I may as well eat ten - CORRECT ANSWER A nurse is
assessing an adolescent client with anorexia. Which of the following client
statements is a sign of cognitive distortion?
A. I like to cut my food into small portions
B. I really need to get in shape
C. If I eat one piece of candy, I may as well eat ten
D. I can’t afford to gain weight
A. Muscle contractions of the neck
B. Fighting behavior
D. Impaired gait - CORRECT ANSWER A nurse is assessing for the presence of
extrapyramidal side effects (EPSs) in a client taking chlorpromazine (Thorazine).
Which of the following findings should the nurse recognize as EPSs? Select all that
apply.
A. Muscle contractions of the neck
B. Fighting behavior
C. Fluctuating vital signs
D. Impaired gait
E. Sexual dysfunction
, B. Tongue twisting and lip-smacking
D. Facial grimacing and eye blinking
F. Repetitive involuntary movements - CORRECT ANSWER A nurse is caring for a
client admitted with acute psychosis, being treated with haloperidol (Haldol.) The
nurse should suspect tardive dyskinesia as an adverse reaction when the client
exhibits which of the following? Select all that apply.
A. Urinary retention and constipation
B. Tongue twisting and lip smacking
C. Fine hand tremors and pill rolling
D. Facial grimacing and eye blinking
E. Extreme sedation and lethargy
Repetitive involuntary movements
A. Denial - CORRECT ANSWER A nurse is caring for a client in an urgent care center
with traumatic injuries following an assault. She sits quietly and calmly in the
exam room. The nurse should recognize this behavior as which of the following?
A. Denial
B. Displacement
C. Introjection
D. Undoing