Question 1:
A nurse is caring for a client diagnosed with schizophrenia. The client
is experiencing auditory hallucinations, stating, "I hear voices telling
me I am going to die." What is the most appropriate nursing
intervention?
A. Encourage the client to ignore the voices.
B. Offer the client a quiet, low-stimulation environment.
C. Dispute the reality of the hallucinations.
D. Teach the client relaxation techniques.
Answer: B. Offer the client a quiet, low-stimulation environment.
Rationale:
Clients experiencing hallucinations may benefit from a calm, quiet
environment to reduce sensory overload. While clients may be
encouraged to use coping strategies such as relaxation techniques, the
first priority is to minimize stimuli that may exacerbate their condition.
Encouraging the client to ignore hallucinations or disputing them may
lead to further distress.
Question 2:
A nurse is teaching a client who has been prescribed a tricyclic
antidepressant (TCA). Which statement by the client indicates the
need for further teaching?
A. "I should avoid drinking alcohol while on this medication."
B. "I should change positions slowly to avoid dizziness."
C. "I may need to take this medication for several months to feel better."
D. "I can stop the medication if I feel better in a few weeks."
Answer: D. "I can stop the medication if I feel better in a few weeks."
,Rationale:
Clients should be instructed to continue taking TCAs for several months
to prevent relapse, even if they feel better. Stopping the medication
abruptly can lead to withdrawal symptoms or relapse of depressive
symptoms. The other statements are correct: alcohol should be avoided
as it can increase the sedative effects of TCAs, orthostatic hypotension
may occur, and the client should be aware that full therapeutic effects
may take several weeks to manifest.
Question 3:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following interventions is most appropriate to include in
the plan of care?
A. Encourage the client to confront stressful situations immediately.
B. Provide a calm and quiet environment to reduce stimulation.
C. Discourage the use of relaxation techniques.
D. Remind the client to avoid social interactions to reduce anxiety.
Answer: B. Provide a calm and quiet environment to reduce
stimulation.
Rationale:
Clients with GAD benefit from a low-stimulation environment to help
reduce anxiety. Encouraging them to confront stressful situations too
quickly may overwhelm them, and relaxation techniques can be
effective in managing symptoms. Social interactions are not to be
avoided unless they increase anxiety, as social support is important in
treatment.
,Question 4:
A nurse is caring for a client with depression. Which of the following
actions should the nurse prioritize when planning care for this client?
A. Encouraging the client to engage in physical activity.
B. Encouraging the client to discuss feelings of hopelessness.
C. Establishing a regular sleep routine.
D. Providing a safe environment and suicide precautions.
Answer: D. Providing a safe environment and suicide precautions.
Rationale:
Safety is the priority when caring for clients with depression,
particularly due to the risk of suicide. Establishing a safe environment
and implementing suicide precautions should always be the first step.
While encouraging physical activity, discussing feelings, and establishing
a sleep routine are important, these interventions are secondary to
ensuring the client is safe.
Question 5:
A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following interventions should the nurse include
in the care plan?
A. Encourage the client to relive traumatic memories to aid in
processing.
B. Allow the client to avoid talking about the trauma if they are not
ready.
C. Suggest that the client participate in group therapy immediately.
D. Remind the client that their feelings of distress are not realistic.
, Answer: B. Allow the client to avoid talking about the trauma if they
are not ready.
Rationale:
For clients with PTSD, it is important to create a safe, non-judgmental
environment where they can choose to process traumatic memories at
their own pace. Pushing clients to relive trauma prematurely can
exacerbate symptoms. Group therapy can be helpful, but only when the
client is ready. It is important to validate the client's feelings rather than
dismiss them.
Question 6:
A nurse is preparing to administer lithium to a client with bipolar
disorder. Which of the following laboratory results is most important
for the nurse to review before administering the medication?
A. Potassium level.
B. Sodium level.
C. Hemoglobin level.
D. White blood cell count.
Answer: B. Sodium level.
Rationale:
Lithium is a mood stabilizer that can affect electrolyte balance,
particularly sodium levels. Low sodium levels can increase the risk of
lithium toxicity. It is important to monitor sodium levels before and
during treatment to avoid complications. Potassium, hemoglobin, and
white blood cell count are not directly impacted by lithium in the same
way.
A nurse is caring for a client diagnosed with schizophrenia. The client
is experiencing auditory hallucinations, stating, "I hear voices telling
me I am going to die." What is the most appropriate nursing
intervention?
A. Encourage the client to ignore the voices.
B. Offer the client a quiet, low-stimulation environment.
C. Dispute the reality of the hallucinations.
D. Teach the client relaxation techniques.
Answer: B. Offer the client a quiet, low-stimulation environment.
Rationale:
Clients experiencing hallucinations may benefit from a calm, quiet
environment to reduce sensory overload. While clients may be
encouraged to use coping strategies such as relaxation techniques, the
first priority is to minimize stimuli that may exacerbate their condition.
Encouraging the client to ignore hallucinations or disputing them may
lead to further distress.
Question 2:
A nurse is teaching a client who has been prescribed a tricyclic
antidepressant (TCA). Which statement by the client indicates the
need for further teaching?
A. "I should avoid drinking alcohol while on this medication."
B. "I should change positions slowly to avoid dizziness."
C. "I may need to take this medication for several months to feel better."
D. "I can stop the medication if I feel better in a few weeks."
Answer: D. "I can stop the medication if I feel better in a few weeks."
,Rationale:
Clients should be instructed to continue taking TCAs for several months
to prevent relapse, even if they feel better. Stopping the medication
abruptly can lead to withdrawal symptoms or relapse of depressive
symptoms. The other statements are correct: alcohol should be avoided
as it can increase the sedative effects of TCAs, orthostatic hypotension
may occur, and the client should be aware that full therapeutic effects
may take several weeks to manifest.
Question 3:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following interventions is most appropriate to include in
the plan of care?
A. Encourage the client to confront stressful situations immediately.
B. Provide a calm and quiet environment to reduce stimulation.
C. Discourage the use of relaxation techniques.
D. Remind the client to avoid social interactions to reduce anxiety.
Answer: B. Provide a calm and quiet environment to reduce
stimulation.
Rationale:
Clients with GAD benefit from a low-stimulation environment to help
reduce anxiety. Encouraging them to confront stressful situations too
quickly may overwhelm them, and relaxation techniques can be
effective in managing symptoms. Social interactions are not to be
avoided unless they increase anxiety, as social support is important in
treatment.
,Question 4:
A nurse is caring for a client with depression. Which of the following
actions should the nurse prioritize when planning care for this client?
A. Encouraging the client to engage in physical activity.
B. Encouraging the client to discuss feelings of hopelessness.
C. Establishing a regular sleep routine.
D. Providing a safe environment and suicide precautions.
Answer: D. Providing a safe environment and suicide precautions.
Rationale:
Safety is the priority when caring for clients with depression,
particularly due to the risk of suicide. Establishing a safe environment
and implementing suicide precautions should always be the first step.
While encouraging physical activity, discussing feelings, and establishing
a sleep routine are important, these interventions are secondary to
ensuring the client is safe.
Question 5:
A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following interventions should the nurse include
in the care plan?
A. Encourage the client to relive traumatic memories to aid in
processing.
B. Allow the client to avoid talking about the trauma if they are not
ready.
C. Suggest that the client participate in group therapy immediately.
D. Remind the client that their feelings of distress are not realistic.
, Answer: B. Allow the client to avoid talking about the trauma if they
are not ready.
Rationale:
For clients with PTSD, it is important to create a safe, non-judgmental
environment where they can choose to process traumatic memories at
their own pace. Pushing clients to relive trauma prematurely can
exacerbate symptoms. Group therapy can be helpful, but only when the
client is ready. It is important to validate the client's feelings rather than
dismiss them.
Question 6:
A nurse is preparing to administer lithium to a client with bipolar
disorder. Which of the following laboratory results is most important
for the nurse to review before administering the medication?
A. Potassium level.
B. Sodium level.
C. Hemoglobin level.
D. White blood cell count.
Answer: B. Sodium level.
Rationale:
Lithium is a mood stabilizer that can affect electrolyte balance,
particularly sodium levels. Low sodium levels can increase the risk of
lithium toxicity. It is important to monitor sodium levels before and
during treatment to avoid complications. Potassium, hemoglobin, and
white blood cell count are not directly impacted by lithium in the same
way.
