Question 1:
A nurse is caring for a client who is experiencing an acute manic
episode. Which of the following interventions is the priority?
A. Provide a high-protein, high-calorie diet
B. Provide a quiet environment
C. Ensure the client’s safety
D. Offer frequent, short, and clear communication
Answer: C. Ensure the client’s safety
Rationale: During a manic episode, clients may engage in risky
behaviors, such as impulsive actions, poor judgment, or aggression. The
priority intervention is to ensure the client’s safety. Although other
interventions like providing a quiet environment or clear
communication are important, safety is the top priority in acute manic
episodes.
Question 2:
A nurse is assessing a client diagnosed with major depressive disorder.
Which of the following findings would be a priority to report to the
healthcare provider?
A. Decreased appetite
B. Low energy
C. Weight loss of 5 lbs in 2 weeks
D. Thoughts of suicide
Answer: D. Thoughts of suicide
Rationale: Although all the listed symptoms are common in depression,
thoughts of suicide are the most urgent and require immediate
intervention. A client with suicidal ideation is at high risk for self-harm
,and should be reported immediately for further assessment and
potential intervention.
Question 3:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following is an appropriate response by the nurse when
the client expresses worry about their upcoming presentation at
work?
A. "Don’t worry, it will be fine."
B. "I understand you are anxious, but your anxiety is unrealistic."
C. "Let’s work together to explore some ways to manage your anxiety."
D. "You shouldn’t feel anxious, it’s just a presentation."
Answer: C. "Let’s work together to explore some ways to manage your
anxiety."
Rationale: Clients with GAD often have excessive and uncontrollable
worry. The best approach is to offer support, explore coping
mechanisms, and help the client manage anxiety. Minimizing or
dismissing the client’s feelings (options A, B, and D) is not therapeutic.
Question 4:
A nurse is planning care for a client with schizophrenia. Which of the
following interventions would be most beneficial in decreasing the
client’s hallucinations?
A. Offer distractions, such as television, to focus the client’s attention.
B. Provide reassurance and tell the client that the voices are not real.
C. Encourage the client to engage in group therapy.
D. Maintain a structured and consistent environment.
, Answer: D. Maintain a structured and consistent environment.
Rationale: A structured environment can help reduce stress and
confusion for clients with schizophrenia. Consistency in routines and
expectations can help decrease the frequency and severity of
hallucinations. Offering reassurance that voices are not real may
increase the client’s anxiety.
Question 5:
A nurse is providing discharge instructions to a client diagnosed with
obsessive-compulsive disorder (OCD). Which of the following
statements by the client indicates a need for further teaching?
A. "I will work with my therapist to identify triggers for my
compulsions."
B. "I will resist the urge to perform my rituals at least 30 minutes each
day."
C. "I will gradually reduce the amount of time I spend on my rituals."
D. "I will avoid situations that trigger my compulsions."
Answer: D. "I will avoid situations that trigger my compulsions."
Rationale: Avoiding triggers for compulsions does not help the client
face and manage their anxiety. The goal of treatment is to gradually
reduce the time spent on compulsions and learn healthier coping
strategies. Working with a therapist (A) and gradually reducing ritual
time (C) are more effective strategies.
Question 6:
A nurse is caring for a client who is experiencing an acute manic
episode. Which of the following interventions is the priority?
A. Provide a high-protein, high-calorie diet
B. Provide a quiet environment
C. Ensure the client’s safety
D. Offer frequent, short, and clear communication
Answer: C. Ensure the client’s safety
Rationale: During a manic episode, clients may engage in risky
behaviors, such as impulsive actions, poor judgment, or aggression. The
priority intervention is to ensure the client’s safety. Although other
interventions like providing a quiet environment or clear
communication are important, safety is the top priority in acute manic
episodes.
Question 2:
A nurse is assessing a client diagnosed with major depressive disorder.
Which of the following findings would be a priority to report to the
healthcare provider?
A. Decreased appetite
B. Low energy
C. Weight loss of 5 lbs in 2 weeks
D. Thoughts of suicide
Answer: D. Thoughts of suicide
Rationale: Although all the listed symptoms are common in depression,
thoughts of suicide are the most urgent and require immediate
intervention. A client with suicidal ideation is at high risk for self-harm
,and should be reported immediately for further assessment and
potential intervention.
Question 3:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following is an appropriate response by the nurse when
the client expresses worry about their upcoming presentation at
work?
A. "Don’t worry, it will be fine."
B. "I understand you are anxious, but your anxiety is unrealistic."
C. "Let’s work together to explore some ways to manage your anxiety."
D. "You shouldn’t feel anxious, it’s just a presentation."
Answer: C. "Let’s work together to explore some ways to manage your
anxiety."
Rationale: Clients with GAD often have excessive and uncontrollable
worry. The best approach is to offer support, explore coping
mechanisms, and help the client manage anxiety. Minimizing or
dismissing the client’s feelings (options A, B, and D) is not therapeutic.
Question 4:
A nurse is planning care for a client with schizophrenia. Which of the
following interventions would be most beneficial in decreasing the
client’s hallucinations?
A. Offer distractions, such as television, to focus the client’s attention.
B. Provide reassurance and tell the client that the voices are not real.
C. Encourage the client to engage in group therapy.
D. Maintain a structured and consistent environment.
, Answer: D. Maintain a structured and consistent environment.
Rationale: A structured environment can help reduce stress and
confusion for clients with schizophrenia. Consistency in routines and
expectations can help decrease the frequency and severity of
hallucinations. Offering reassurance that voices are not real may
increase the client’s anxiety.
Question 5:
A nurse is providing discharge instructions to a client diagnosed with
obsessive-compulsive disorder (OCD). Which of the following
statements by the client indicates a need for further teaching?
A. "I will work with my therapist to identify triggers for my
compulsions."
B. "I will resist the urge to perform my rituals at least 30 minutes each
day."
C. "I will gradually reduce the amount of time I spend on my rituals."
D. "I will avoid situations that trigger my compulsions."
Answer: D. "I will avoid situations that trigger my compulsions."
Rationale: Avoiding triggers for compulsions does not help the client
face and manage their anxiety. The goal of treatment is to gradually
reduce the time spent on compulsions and learn healthier coping
strategies. Working with a therapist (A) and gradually reducing ritual
time (C) are more effective strategies.
Question 6:
