1. Question:
A client diagnosed with schizophrenia is experiencing auditory
hallucinations. Which of the following is the most appropriate nursing
response?
a) “I know you’re hearing voices, but they aren’t real.”
b) “Try to ignore the voices and focus on something else.”
c) “I understand the voices are disturbing, but I’m here to talk with
you.”
d) “Can you tell me what the voices are saying to you right now?”
Answer: c) “I understand the voices are disturbing, but I’m here to talk
with you.”
Rationale: The most appropriate response acknowledges the client’s
experience and offers support. It is important to be empathetic and
present with the client rather than denying or minimizing their
hallucinations. Avoid dismissing their experience.
2. Question:
A nurse is caring for a client diagnosed with depression. The client
states, "I don't see the point in living anymore." What is the priority
action for the nurse?
a) Ask the client about their support system.
b) Encourage the client to engage in activities.
c) Assess the client’s risk for suicide.
d) Offer reassurances that things will get better.
Answer: c) Assess the client’s risk for suicide.
Rationale: The priority action is to assess for suicide risk, as this is a life-
threatening situation. Identifying suicidal ideation and implementing
appropriate interventions (e.g., safety measures) is crucial.
,3. Question:
A nurse is providing discharge teaching for a client prescribed lithium
carbonate for bipolar disorder. Which of the following statements by
the client indicates a need for further teaching?
a) "I should drink plenty of fluids while taking this medication."
b) "I will take this medication even when I feel better."
c) "I need to avoid foods high in sodium while taking this medication."
d) "I should get my thyroid function tested regularly."
Answer: c) "I need to avoid foods high in sodium while taking this
medication."
Rationale: Clients taking lithium should maintain a consistent intake of
sodium. A decrease in sodium intake can increase lithium levels and
potentially cause toxicity. It is important not to avoid sodium, but to
consume it in a balanced way.
4. Question:
A nurse is assessing a client who has been diagnosed with generalized
anxiety disorder (GAD). Which of the following behaviors is the nurse
most likely to observe?
a) Excessive worry about everyday situations.
b) Extreme mood swings.
c) Panic attacks with physical symptoms.
d) Unexplained, irrational fears of specific objects or situations.
Answer: a) Excessive worry about everyday situations.
Rationale: GAD is characterized by excessive and uncontrollable worry
about daily life events or situations. The other options are more
, characteristic of other disorders (e.g., panic disorder or specific
phobias).
5. Question:
A nurse is caring for a client receiving fluoxetine for depression. The
nurse recognizes which of the following as a serious adverse effect
associated with this medication?
a) Diarrhea
b) Insomnia
c) Serotonin syndrome
d) Weight gain
Answer: c) Serotonin syndrome
Rationale: Serotonin syndrome is a serious adverse effect of SSRIs (e.g.,
fluoxetine). It can present with symptoms such as agitation, confusion,
hyperreflexia, fever, and autonomic dysfunction. It requires immediate
medical attention.
6. Question:
A nurse is assessing a client with a history of substance use disorder.
Which of the following findings indicates the need for further
assessment for alcohol withdrawal?
a) Bradycardia
b) Anxiety and tremors
c) Hypotension
d) Decreased reflexes
Answer: b) Anxiety and tremors
Rationale: Anxiety, tremors, and other symptoms such as tachycardia
and sweating are signs of alcohol withdrawal, which can occur within
A client diagnosed with schizophrenia is experiencing auditory
hallucinations. Which of the following is the most appropriate nursing
response?
a) “I know you’re hearing voices, but they aren’t real.”
b) “Try to ignore the voices and focus on something else.”
c) “I understand the voices are disturbing, but I’m here to talk with
you.”
d) “Can you tell me what the voices are saying to you right now?”
Answer: c) “I understand the voices are disturbing, but I’m here to talk
with you.”
Rationale: The most appropriate response acknowledges the client’s
experience and offers support. It is important to be empathetic and
present with the client rather than denying or minimizing their
hallucinations. Avoid dismissing their experience.
2. Question:
A nurse is caring for a client diagnosed with depression. The client
states, "I don't see the point in living anymore." What is the priority
action for the nurse?
a) Ask the client about their support system.
b) Encourage the client to engage in activities.
c) Assess the client’s risk for suicide.
d) Offer reassurances that things will get better.
Answer: c) Assess the client’s risk for suicide.
Rationale: The priority action is to assess for suicide risk, as this is a life-
threatening situation. Identifying suicidal ideation and implementing
appropriate interventions (e.g., safety measures) is crucial.
,3. Question:
A nurse is providing discharge teaching for a client prescribed lithium
carbonate for bipolar disorder. Which of the following statements by
the client indicates a need for further teaching?
a) "I should drink plenty of fluids while taking this medication."
b) "I will take this medication even when I feel better."
c) "I need to avoid foods high in sodium while taking this medication."
d) "I should get my thyroid function tested regularly."
Answer: c) "I need to avoid foods high in sodium while taking this
medication."
Rationale: Clients taking lithium should maintain a consistent intake of
sodium. A decrease in sodium intake can increase lithium levels and
potentially cause toxicity. It is important not to avoid sodium, but to
consume it in a balanced way.
4. Question:
A nurse is assessing a client who has been diagnosed with generalized
anxiety disorder (GAD). Which of the following behaviors is the nurse
most likely to observe?
a) Excessive worry about everyday situations.
b) Extreme mood swings.
c) Panic attacks with physical symptoms.
d) Unexplained, irrational fears of specific objects or situations.
Answer: a) Excessive worry about everyday situations.
Rationale: GAD is characterized by excessive and uncontrollable worry
about daily life events or situations. The other options are more
, characteristic of other disorders (e.g., panic disorder or specific
phobias).
5. Question:
A nurse is caring for a client receiving fluoxetine for depression. The
nurse recognizes which of the following as a serious adverse effect
associated with this medication?
a) Diarrhea
b) Insomnia
c) Serotonin syndrome
d) Weight gain
Answer: c) Serotonin syndrome
Rationale: Serotonin syndrome is a serious adverse effect of SSRIs (e.g.,
fluoxetine). It can present with symptoms such as agitation, confusion,
hyperreflexia, fever, and autonomic dysfunction. It requires immediate
medical attention.
6. Question:
A nurse is assessing a client with a history of substance use disorder.
Which of the following findings indicates the need for further
assessment for alcohol withdrawal?
a) Bradycardia
b) Anxiety and tremors
c) Hypotension
d) Decreased reflexes
Answer: b) Anxiety and tremors
Rationale: Anxiety, tremors, and other symptoms such as tachycardia
and sweating are signs of alcohol withdrawal, which can occur within
