1. Question:
A nurse is working with a client who has major depressive disorder
(MDD). Which of the following should the nurse identify as a priority
intervention during the initial phase of treatment?
A) Encouraging the client to participate in group therapy
B) Discussing the client's feelings of guilt
C) Providing a safe environment to prevent self-harm
D) Teaching the client coping mechanisms
Answer: C) Providing a safe environment to prevent self-harm
Rationale: The priority during the initial phase of treatment for a client
with MDD is to ensure safety and prevent self-harm or suicide. This can
be done by creating a safe environment and continuously assessing the
client's risk for self-harm. The other interventions (group therapy, guilt
discussions, teaching coping mechanisms) are important but secondary
once safety is assured.
2. Question:
A nurse is caring for a client diagnosed with schizophrenia who is
experiencing auditory hallucinations. The nurse should take which of
the following actions?
A) Reassure the client that the voices are not real.
B) Acknowledge the hallucinations and focus on reality-based
conversation.
C) Encourage the client to ignore the voices.
D) Provide the client with a quiet room to isolate from others.
Answer: B) Acknowledge the hallucinations and focus on reality-based
conversation.
,Rationale: The nurse should acknowledge the hallucinations but
redirect the client toward reality-based thinking. Denying or ignoring
the hallucinations can increase the client’s anxiety. Isolation is not
recommended unless needed for safety, as social interaction can be
therapeutic.
3. Question:
A client with generalized anxiety disorder (GAD) is prescribed diazepam
(Valium). The nurse should explain which of the following potential
adverse effects of this medication?
A) Weight gain
B) Increased heart rate
C) Drowsiness and sedation
D) Dehydration
Answer: C) Drowsiness and sedation
Rationale: Diazepam is a benzodiazepine that can cause sedation and
drowsiness as common side effects. It is important to educate the client
on the potential for these effects and advise them to avoid activities
such as driving until they understand how the medication affects them.
4. Question:
A nurse is caring for a client who has post-traumatic stress disorder
(PTSD) and is experiencing hyperarousal symptoms. Which of the
following interventions is most appropriate?
A) Encourage relaxation techniques, such as deep breathing
B) Discuss the traumatic event to help the client process it
, C) Encourage the client to avoid situations that may trigger memories
D) Provide a structured, predictable environment
Answer: A) Encourage relaxation techniques, such as deep breathing
Rationale: Relaxation techniques such as deep breathing are effective in
managing hyperarousal symptoms of PTSD. These interventions help
reduce anxiety and promote relaxation. While a predictable
environment is helpful, relaxation techniques are essential for
immediate symptom relief.
5. Question:
A nurse is caring for a client who has been diagnosed with obsessive-
compulsive disorder (OCD). Which of the following statements by the
client indicates an understanding of the treatment plan?
A) "I will be able to stop my compulsions after a few therapy sessions."
B) "I need to keep performing my rituals, but I can gradually reduce
them."
C) "Medication will stop my obsessions immediately."
D) "I should avoid any exposure to situations that cause my obsessions."
Answer: B) "I need to keep performing my rituals, but I can gradually
reduce them."
Rationale: In treating OCD, clients typically learn to gradually reduce
their compulsive behaviors over time, often with the help of exposure
and response prevention therapy. Clients should not be expected to
stop their compulsions immediately. Medication can help with
symptoms, but it is not a quick fix.
6. Question:
A nurse is working with a client who has major depressive disorder
(MDD). Which of the following should the nurse identify as a priority
intervention during the initial phase of treatment?
A) Encouraging the client to participate in group therapy
B) Discussing the client's feelings of guilt
C) Providing a safe environment to prevent self-harm
D) Teaching the client coping mechanisms
Answer: C) Providing a safe environment to prevent self-harm
Rationale: The priority during the initial phase of treatment for a client
with MDD is to ensure safety and prevent self-harm or suicide. This can
be done by creating a safe environment and continuously assessing the
client's risk for self-harm. The other interventions (group therapy, guilt
discussions, teaching coping mechanisms) are important but secondary
once safety is assured.
2. Question:
A nurse is caring for a client diagnosed with schizophrenia who is
experiencing auditory hallucinations. The nurse should take which of
the following actions?
A) Reassure the client that the voices are not real.
B) Acknowledge the hallucinations and focus on reality-based
conversation.
C) Encourage the client to ignore the voices.
D) Provide the client with a quiet room to isolate from others.
Answer: B) Acknowledge the hallucinations and focus on reality-based
conversation.
,Rationale: The nurse should acknowledge the hallucinations but
redirect the client toward reality-based thinking. Denying or ignoring
the hallucinations can increase the client’s anxiety. Isolation is not
recommended unless needed for safety, as social interaction can be
therapeutic.
3. Question:
A client with generalized anxiety disorder (GAD) is prescribed diazepam
(Valium). The nurse should explain which of the following potential
adverse effects of this medication?
A) Weight gain
B) Increased heart rate
C) Drowsiness and sedation
D) Dehydration
Answer: C) Drowsiness and sedation
Rationale: Diazepam is a benzodiazepine that can cause sedation and
drowsiness as common side effects. It is important to educate the client
on the potential for these effects and advise them to avoid activities
such as driving until they understand how the medication affects them.
4. Question:
A nurse is caring for a client who has post-traumatic stress disorder
(PTSD) and is experiencing hyperarousal symptoms. Which of the
following interventions is most appropriate?
A) Encourage relaxation techniques, such as deep breathing
B) Discuss the traumatic event to help the client process it
, C) Encourage the client to avoid situations that may trigger memories
D) Provide a structured, predictable environment
Answer: A) Encourage relaxation techniques, such as deep breathing
Rationale: Relaxation techniques such as deep breathing are effective in
managing hyperarousal symptoms of PTSD. These interventions help
reduce anxiety and promote relaxation. While a predictable
environment is helpful, relaxation techniques are essential for
immediate symptom relief.
5. Question:
A nurse is caring for a client who has been diagnosed with obsessive-
compulsive disorder (OCD). Which of the following statements by the
client indicates an understanding of the treatment plan?
A) "I will be able to stop my compulsions after a few therapy sessions."
B) "I need to keep performing my rituals, but I can gradually reduce
them."
C) "Medication will stop my obsessions immediately."
D) "I should avoid any exposure to situations that cause my obsessions."
Answer: B) "I need to keep performing my rituals, but I can gradually
reduce them."
Rationale: In treating OCD, clients typically learn to gradually reduce
their compulsive behaviors over time, often with the help of exposure
and response prevention therapy. Clients should not be expected to
stop their compulsions immediately. Medication can help with
symptoms, but it is not a quick fix.
6. Question:
