1. Question:
A nurse is working with a client diagnosed with major depressive
disorder. The client reports feeling "numb" and unable to experience
joy. Which intervention should the nurse prioritize?
A) Encouraging the client to participate in an enjoyable activity B)
Educating the client about the side effects of antidepressants C)
Assessing the client's suicidal ideation and risk D) Teaching the client
stress management techniques
Answer: C) Assessing the client's suicidal ideation and risk
Rationale: The priority concern for a client with depression is the risk of
suicide. The nurse must assess the client's suicidal ideation to ensure
the safety of the client. While other interventions are important, they
are secondary to ensuring the client is not at immediate risk for harm.
2. Question:
A client diagnosed with schizophrenia tells the nurse, "I am the
president of the United States." Which response by the nurse is
appropriate?
A) "You are not the president. Let's focus on reality." B) "I understand
that you believe you are the president. Let's talk about your feelings." C)
"Why do you think you're the president?" D) "That must be stressful.
Let’s talk about your responsibilities."
Answer: B) "I understand that you believe you are the president. Let's
talk about your feelings."
Rationale: The nurse should acknowledge the client’s delusion without
reinforcing it. By validating the client's belief and focusing on feelings,
,the nurse provides support without reinforcing the false belief. It's
important to maintain therapeutic communication.
3. Question:
A nurse is caring for a client with a history of panic disorder. The client
experiences a panic attack and begins to hyperventilate. Which action
should the nurse take first?
A) Provide reassurance that the attack will soon end. B) Encourage the
client to take deep, slow breaths. C) Administer anti-anxiety medication
as prescribed. D) Ask the client to leave the room and return when
calm.
Answer: B) Encourage the client to take deep, slow breaths.
Rationale: During a panic attack, hyperventilation can occur. The first
intervention is to guide the client in controlled breathing to reduce the
symptoms of hyperventilation and anxiety. This helps the client regain
control over their breathing and reduce distress.
4. Question:
A nurse is caring for a client who is newly prescribed lithium for bipolar
disorder. Which laboratory result would be of most concern?
A) Sodium level of 134 mEq/L B) Potassium level of 4.2 mEq/L C) Lithium
level of 1.5 mEq/L D) Glucose level of 110 mg/dL
Answer: C) Lithium level of 1.5 mEq/L
Rationale: A lithium level of 1.5 mEq/L is above the therapeutic range
(0.6-1.2 mEq/L), which puts the client at risk for lithium toxicity.
, Symptoms of toxicity include tremors, confusion, and ataxia. Immediate
intervention is required.
5. Question:
A nurse is assessing a client with borderline personality disorder. Which
behavior would the nurse expect to observe?
A) Consistent and stable interpersonal relationships B) Inflexible and
rigid thought patterns C) Intense fear of abandonment and unstable
relationships D) Avoidance of social situations due to social anxiety
Answer: C) Intense fear of abandonment and unstable relationships
Rationale: Clients with borderline personality disorder often have
unstable relationships, intense emotional responses, and a fear of
abandonment. This is characteristic of the disorder, along with
impulsive behaviors and difficulty maintaining relationships.
6. Question:
A nurse is caring for a client who has been diagnosed with obsessive-
compulsive disorder (OCD). The client spends hours each day washing
their hands. Which intervention is most appropriate?
A) Limit the time spent washing hands to 15 minutes per day. B) Allow
the client to wash their hands as needed, but encourage social
interaction. C) Encourage the client to focus on thoughts of relaxation
while performing the compulsion. D) Offer praise for completing
activities unrelated to hand washing.
Answer: B) Allow the client to wash their hands as needed, but
encourage social interaction.
A nurse is working with a client diagnosed with major depressive
disorder. The client reports feeling "numb" and unable to experience
joy. Which intervention should the nurse prioritize?
A) Encouraging the client to participate in an enjoyable activity B)
Educating the client about the side effects of antidepressants C)
Assessing the client's suicidal ideation and risk D) Teaching the client
stress management techniques
Answer: C) Assessing the client's suicidal ideation and risk
Rationale: The priority concern for a client with depression is the risk of
suicide. The nurse must assess the client's suicidal ideation to ensure
the safety of the client. While other interventions are important, they
are secondary to ensuring the client is not at immediate risk for harm.
2. Question:
A client diagnosed with schizophrenia tells the nurse, "I am the
president of the United States." Which response by the nurse is
appropriate?
A) "You are not the president. Let's focus on reality." B) "I understand
that you believe you are the president. Let's talk about your feelings." C)
"Why do you think you're the president?" D) "That must be stressful.
Let’s talk about your responsibilities."
Answer: B) "I understand that you believe you are the president. Let's
talk about your feelings."
Rationale: The nurse should acknowledge the client’s delusion without
reinforcing it. By validating the client's belief and focusing on feelings,
,the nurse provides support without reinforcing the false belief. It's
important to maintain therapeutic communication.
3. Question:
A nurse is caring for a client with a history of panic disorder. The client
experiences a panic attack and begins to hyperventilate. Which action
should the nurse take first?
A) Provide reassurance that the attack will soon end. B) Encourage the
client to take deep, slow breaths. C) Administer anti-anxiety medication
as prescribed. D) Ask the client to leave the room and return when
calm.
Answer: B) Encourage the client to take deep, slow breaths.
Rationale: During a panic attack, hyperventilation can occur. The first
intervention is to guide the client in controlled breathing to reduce the
symptoms of hyperventilation and anxiety. This helps the client regain
control over their breathing and reduce distress.
4. Question:
A nurse is caring for a client who is newly prescribed lithium for bipolar
disorder. Which laboratory result would be of most concern?
A) Sodium level of 134 mEq/L B) Potassium level of 4.2 mEq/L C) Lithium
level of 1.5 mEq/L D) Glucose level of 110 mg/dL
Answer: C) Lithium level of 1.5 mEq/L
Rationale: A lithium level of 1.5 mEq/L is above the therapeutic range
(0.6-1.2 mEq/L), which puts the client at risk for lithium toxicity.
, Symptoms of toxicity include tremors, confusion, and ataxia. Immediate
intervention is required.
5. Question:
A nurse is assessing a client with borderline personality disorder. Which
behavior would the nurse expect to observe?
A) Consistent and stable interpersonal relationships B) Inflexible and
rigid thought patterns C) Intense fear of abandonment and unstable
relationships D) Avoidance of social situations due to social anxiety
Answer: C) Intense fear of abandonment and unstable relationships
Rationale: Clients with borderline personality disorder often have
unstable relationships, intense emotional responses, and a fear of
abandonment. This is characteristic of the disorder, along with
impulsive behaviors and difficulty maintaining relationships.
6. Question:
A nurse is caring for a client who has been diagnosed with obsessive-
compulsive disorder (OCD). The client spends hours each day washing
their hands. Which intervention is most appropriate?
A) Limit the time spent washing hands to 15 minutes per day. B) Allow
the client to wash their hands as needed, but encourage social
interaction. C) Encourage the client to focus on thoughts of relaxation
while performing the compulsion. D) Offer praise for completing
activities unrelated to hand washing.
Answer: B) Allow the client to wash their hands as needed, but
encourage social interaction.
