1. Question:
A nurse is caring for a client with generalized anxiety disorder
(GAD). Which of the following interventions should the nurse
prioritize?
A) Encouraging the client to engage in physical exercise
B) Assisting the client in identifying their anxiety triggers
C) Recommending the use of relaxation techniques
D) Providing a calm, quiet environment
Answer: D) Providing a calm, quiet environment
Rationale: Clients with GAD often experience heightened
anxiety. A calm, quiet environment helps reduce stimuli and
provides the client with a sense of safety, which can decrease
anxiety. While the other options are helpful in managing
anxiety, creating a calming environment is the priority
intervention in the acute phase.
2. Question:
A client with schizophrenia is demonstrating a belief that
people are reading their mind. Which of the following is the
nurse’s most appropriate response?
A) “I don’t believe anyone is reading your mind, but I
understand you are feeling frightened.”
B) “Don’t worry, nobody is reading your mind.”
C) “Let’s talk about your experiences with mind-reading.”
D) “That’s not possible, it’s just your imagination.”
,Answer: A) “I don’t believe anyone is reading your mind, but I
understand you are feeling frightened.”
Rationale: When working with clients experiencing delusions, it
is important to acknowledge their feelings without validating
the delusion. This response shows empathy while gently
challenging the belief, which can help build trust and reduce
anxiety.
3. Question:
A nurse is caring for a client with major depressive disorder.
Which of the following findings is a priority to report to the
healthcare provider?
A) The client expresses feelings of worthlessness
B) The client is no longer able to concentrate
C) The client has gained weight
D) The client expresses suicidal thoughts
Answer: D) The client expresses suicidal thoughts
Rationale: Suicidal ideation is a priority concern in any client
with depression and requires immediate intervention. Ensuring
the client’s safety is the primary goal.
4. Question:
A client with bipolar disorder is experiencing a manic episode.
Which of the following interventions should the nurse
,prioritize?
A) Encourage the client to engage in social activities
B) Set firm limits on the client’s behavior
C) Provide the client with frequent snacks to manage weight
loss
D) Allow the client to express their thoughts freely during
interactions
Answer: B) Set firm limits on the client’s behavior
Rationale: During a manic episode, clients may display
impulsive or inappropriate behaviors. Setting clear boundaries
is important to help the client maintain safety and prevent
harm to themselves or others. It is not appropriate to
encourage social activities or allow unstructured expression, as
this could escalate the mania.
5. Question:
A nurse is assessing a client with post-traumatic stress disorder
(PTSD). Which of the following findings should the nurse
expect?
A) Compulsive behavior
B) Flashbacks to traumatic events
C) Excessive talkativeness
D) Delusions of grandeur
Answer: B) Flashbacks to traumatic events
, Rationale: Flashbacks are a hallmark symptom of PTSD, where
clients relive traumatic events as though they are happening in
the present. Compulsive behavior, excessive talkativeness, and
delusions of grandeur are not typically associated with PTSD.
6. Question:
A client is admitted for alcohol detoxification. The nurse
assesses that the client is experiencing tremors, sweating, and
elevated blood pressure. Which of the following actions is the
nurse’s priority?
A) Administer prescribed benzodiazepines
B) Offer fluids to the client
C) Monitor for signs of seizures
D) Place the client in a quiet, dark room
Answer: A) Administer prescribed benzodiazepines
Rationale: Benzodiazepines are commonly used to manage
alcohol withdrawal symptoms and prevent complications such
as seizures. Tremors, sweating, and elevated blood pressure
indicate withdrawal, and medication is often needed to stabilize
the client’s condition.
7. Question:
A nurse is teaching a client with a diagnosis of obsessive-
compulsive disorder (OCD) about the nature of the disorder.
A nurse is caring for a client with generalized anxiety disorder
(GAD). Which of the following interventions should the nurse
prioritize?
A) Encouraging the client to engage in physical exercise
B) Assisting the client in identifying their anxiety triggers
C) Recommending the use of relaxation techniques
D) Providing a calm, quiet environment
Answer: D) Providing a calm, quiet environment
Rationale: Clients with GAD often experience heightened
anxiety. A calm, quiet environment helps reduce stimuli and
provides the client with a sense of safety, which can decrease
anxiety. While the other options are helpful in managing
anxiety, creating a calming environment is the priority
intervention in the acute phase.
2. Question:
A client with schizophrenia is demonstrating a belief that
people are reading their mind. Which of the following is the
nurse’s most appropriate response?
A) “I don’t believe anyone is reading your mind, but I
understand you are feeling frightened.”
B) “Don’t worry, nobody is reading your mind.”
C) “Let’s talk about your experiences with mind-reading.”
D) “That’s not possible, it’s just your imagination.”
,Answer: A) “I don’t believe anyone is reading your mind, but I
understand you are feeling frightened.”
Rationale: When working with clients experiencing delusions, it
is important to acknowledge their feelings without validating
the delusion. This response shows empathy while gently
challenging the belief, which can help build trust and reduce
anxiety.
3. Question:
A nurse is caring for a client with major depressive disorder.
Which of the following findings is a priority to report to the
healthcare provider?
A) The client expresses feelings of worthlessness
B) The client is no longer able to concentrate
C) The client has gained weight
D) The client expresses suicidal thoughts
Answer: D) The client expresses suicidal thoughts
Rationale: Suicidal ideation is a priority concern in any client
with depression and requires immediate intervention. Ensuring
the client’s safety is the primary goal.
4. Question:
A client with bipolar disorder is experiencing a manic episode.
Which of the following interventions should the nurse
,prioritize?
A) Encourage the client to engage in social activities
B) Set firm limits on the client’s behavior
C) Provide the client with frequent snacks to manage weight
loss
D) Allow the client to express their thoughts freely during
interactions
Answer: B) Set firm limits on the client’s behavior
Rationale: During a manic episode, clients may display
impulsive or inappropriate behaviors. Setting clear boundaries
is important to help the client maintain safety and prevent
harm to themselves or others. It is not appropriate to
encourage social activities or allow unstructured expression, as
this could escalate the mania.
5. Question:
A nurse is assessing a client with post-traumatic stress disorder
(PTSD). Which of the following findings should the nurse
expect?
A) Compulsive behavior
B) Flashbacks to traumatic events
C) Excessive talkativeness
D) Delusions of grandeur
Answer: B) Flashbacks to traumatic events
, Rationale: Flashbacks are a hallmark symptom of PTSD, where
clients relive traumatic events as though they are happening in
the present. Compulsive behavior, excessive talkativeness, and
delusions of grandeur are not typically associated with PTSD.
6. Question:
A client is admitted for alcohol detoxification. The nurse
assesses that the client is experiencing tremors, sweating, and
elevated blood pressure. Which of the following actions is the
nurse’s priority?
A) Administer prescribed benzodiazepines
B) Offer fluids to the client
C) Monitor for signs of seizures
D) Place the client in a quiet, dark room
Answer: A) Administer prescribed benzodiazepines
Rationale: Benzodiazepines are commonly used to manage
alcohol withdrawal symptoms and prevent complications such
as seizures. Tremors, sweating, and elevated blood pressure
indicate withdrawal, and medication is often needed to stabilize
the client’s condition.
7. Question:
A nurse is teaching a client with a diagnosis of obsessive-
compulsive disorder (OCD) about the nature of the disorder.
