1. Question:
A nurse is caring for a client who is experiencing a manic episode
associated with bipolar disorder. Which of the following interventions
should the nurse prioritize?
• A. Encourage the client to rest in a quiet room.
• B. Provide the client with a high-protein, high-calorie snack.
• C. Administer an anxiolytic medication.
• D. Set firm limits on the client’s behavior.
Answer: B. Provide the client with a high-protein, high-calorie snack.
Rationale: Clients in a manic episode are often hyperactive and may
have a reduced ability to focus on meals. Offering high-protein, high-
calorie snacks helps maintain nutritional intake. Resting in a quiet room
(Option A) may not be feasible for a client experiencing a manic episode
due to their high energy level. Anxiolytics (Option C) are not the first-
line treatment for mania, and setting limits (Option D) is important but
should be used in conjunction with other interventions for safety.
2. Question:
A client with schizophrenia tells the nurse, "I can hear voices telling me
to hurt myself." What is the nurse's most appropriate response?
• A. "Don't worry, those voices are not real."
• B. "I understand you're hearing voices. Let's talk about how you're
feeling."
• C. "You should not listen to those voices."
• D. "You need to stop thinking those things immediately."
,Answer: B. "I understand you're hearing voices. Let's talk about how
you're feeling."
Rationale: It is essential to acknowledge the client's experience of
hearing voices, as this demonstrates empathy and support. Encouraging
the client to talk about their feelings may help assess the severity of the
situation. Denying the reality of the voices (Option A) or instructing the
client to ignore them (Options C and D) may invalidate the client's
feelings and worsen their distress.
3. Question:
A nurse is assessing a client diagnosed with post-traumatic stress
disorder (PTSD). Which of the following findings would the nurse expect
to observe?
• A. Increased appetite and sleep disturbances
• B. Flashbacks, hypervigilance, and avoidance behaviors
• C. Lack of emotion, disorientation, and confusion
• D. Excessive energy, racing thoughts, and rapid speech
Answer: B. Flashbacks, hypervigilance, and avoidance behaviors
Rationale: Clients with PTSD often experience flashbacks,
hypervigilance, and avoidance of situations or people that remind them
of the trauma. Increased appetite and sleep disturbances (Option A) can
occur but are less specific to PTSD. Lack of emotion and confusion
(Option C) is more associated with dissociative disorders, while
excessive energy and racing thoughts (Option D) are more indicative of
mania.
,4. Question:
Which of the following behaviors is most commonly associated with
borderline personality disorder?
• A. Obsessive-compulsive behavior and rigidity
• B. Intense fear of abandonment and unstable relationships
• C. Grandiosity and need for admiration
• D. Avoidance of social situations and extreme shyness
Answer: B. Intense fear of abandonment and unstable relationships
Rationale: Individuals with borderline personality disorder often have
unstable relationships and a chronic fear of abandonment, which leads
to emotional instability. Obsessive-compulsive behavior (Option A) is
associated with obsessive-compulsive personality disorder, while
grandiosity (Option C) is linked to narcissistic personality disorder, and
avoidance of social situations (Option D) is characteristic of avoidant
personality disorder.
5. Question:
A nurse is providing education to a client newly diagnosed with major
depressive disorder. Which of the following statements by the client
indicates the need for further teaching?
• A. "I may have a loss of interest in activities I used to enjoy."
• B. "I might experience difficulty sleeping or excessive sleeping."
• C. "My mood will probably improve immediately after starting my
medication."
• D. "I may feel fatigued and have trouble concentrating."
, Answer: C. "My mood will probably improve immediately after
starting my medication."
Rationale: Antidepressant medications typically take several weeks to
show their full effect. Clients should be educated that immediate
improvement is not expected. Loss of interest in activities, changes in
sleep patterns, fatigue, and trouble concentrating (Options A, B, D) are
all common symptoms of depression.
6. Question:
A nurse is caring for a client who is admitted with alcohol withdrawal.
Which of the following signs should the nurse monitor for in the first 12
to 24 hours after admission?
• A. Hypotension and bradycardia
• B. Seizures and tremors
• C. Auditory hallucinations and delusions
• D. Increased energy and hyperactivity
Answer: B. Seizures and tremors
Rationale: Seizures and tremors are common symptoms of alcohol
withdrawal and typically occur within 12 to 24 hours. Hypotension and
bradycardia (Option A) are less common in alcohol withdrawal. Auditory
hallucinations and delusions (Option C) may occur later in withdrawal,
and increased energy (Option D) is not typically seen in the initial stages
of withdrawal.
7. Question:
A nurse is caring for a client who is experiencing a manic episode
associated with bipolar disorder. Which of the following interventions
should the nurse prioritize?
• A. Encourage the client to rest in a quiet room.
• B. Provide the client with a high-protein, high-calorie snack.
• C. Administer an anxiolytic medication.
• D. Set firm limits on the client’s behavior.
Answer: B. Provide the client with a high-protein, high-calorie snack.
Rationale: Clients in a manic episode are often hyperactive and may
have a reduced ability to focus on meals. Offering high-protein, high-
calorie snacks helps maintain nutritional intake. Resting in a quiet room
(Option A) may not be feasible for a client experiencing a manic episode
due to their high energy level. Anxiolytics (Option C) are not the first-
line treatment for mania, and setting limits (Option D) is important but
should be used in conjunction with other interventions for safety.
2. Question:
A client with schizophrenia tells the nurse, "I can hear voices telling me
to hurt myself." What is the nurse's most appropriate response?
• A. "Don't worry, those voices are not real."
• B. "I understand you're hearing voices. Let's talk about how you're
feeling."
• C. "You should not listen to those voices."
• D. "You need to stop thinking those things immediately."
,Answer: B. "I understand you're hearing voices. Let's talk about how
you're feeling."
Rationale: It is essential to acknowledge the client's experience of
hearing voices, as this demonstrates empathy and support. Encouraging
the client to talk about their feelings may help assess the severity of the
situation. Denying the reality of the voices (Option A) or instructing the
client to ignore them (Options C and D) may invalidate the client's
feelings and worsen their distress.
3. Question:
A nurse is assessing a client diagnosed with post-traumatic stress
disorder (PTSD). Which of the following findings would the nurse expect
to observe?
• A. Increased appetite and sleep disturbances
• B. Flashbacks, hypervigilance, and avoidance behaviors
• C. Lack of emotion, disorientation, and confusion
• D. Excessive energy, racing thoughts, and rapid speech
Answer: B. Flashbacks, hypervigilance, and avoidance behaviors
Rationale: Clients with PTSD often experience flashbacks,
hypervigilance, and avoidance of situations or people that remind them
of the trauma. Increased appetite and sleep disturbances (Option A) can
occur but are less specific to PTSD. Lack of emotion and confusion
(Option C) is more associated with dissociative disorders, while
excessive energy and racing thoughts (Option D) are more indicative of
mania.
,4. Question:
Which of the following behaviors is most commonly associated with
borderline personality disorder?
• A. Obsessive-compulsive behavior and rigidity
• B. Intense fear of abandonment and unstable relationships
• C. Grandiosity and need for admiration
• D. Avoidance of social situations and extreme shyness
Answer: B. Intense fear of abandonment and unstable relationships
Rationale: Individuals with borderline personality disorder often have
unstable relationships and a chronic fear of abandonment, which leads
to emotional instability. Obsessive-compulsive behavior (Option A) is
associated with obsessive-compulsive personality disorder, while
grandiosity (Option C) is linked to narcissistic personality disorder, and
avoidance of social situations (Option D) is characteristic of avoidant
personality disorder.
5. Question:
A nurse is providing education to a client newly diagnosed with major
depressive disorder. Which of the following statements by the client
indicates the need for further teaching?
• A. "I may have a loss of interest in activities I used to enjoy."
• B. "I might experience difficulty sleeping or excessive sleeping."
• C. "My mood will probably improve immediately after starting my
medication."
• D. "I may feel fatigued and have trouble concentrating."
, Answer: C. "My mood will probably improve immediately after
starting my medication."
Rationale: Antidepressant medications typically take several weeks to
show their full effect. Clients should be educated that immediate
improvement is not expected. Loss of interest in activities, changes in
sleep patterns, fatigue, and trouble concentrating (Options A, B, D) are
all common symptoms of depression.
6. Question:
A nurse is caring for a client who is admitted with alcohol withdrawal.
Which of the following signs should the nurse monitor for in the first 12
to 24 hours after admission?
• A. Hypotension and bradycardia
• B. Seizures and tremors
• C. Auditory hallucinations and delusions
• D. Increased energy and hyperactivity
Answer: B. Seizures and tremors
Rationale: Seizures and tremors are common symptoms of alcohol
withdrawal and typically occur within 12 to 24 hours. Hypotension and
bradycardia (Option A) are less common in alcohol withdrawal. Auditory
hallucinations and delusions (Option C) may occur later in withdrawal,
and increased energy (Option D) is not typically seen in the initial stages
of withdrawal.
7. Question:
