1. Question: A nurse is caring for a client who has been diagnosed
with generalized anxiety disorder (GAD). Which of the following is the
priority intervention?
A. Encourage the client to verbalize feelings
B. Establish a calm environment with minimal stimulation
C. Offer the client information about relaxation techniques
D. Assist the client with identifying triggers for anxiety
Answer: B. Establish a calm environment with minimal stimulation
Rationale: In clients with GAD, anxiety can be overwhelming, and a
calm environment helps to reduce external stressors and allows the
client to regain a sense of control. This is the priority intervention
because it ensures safety and creates a foundation for further
therapeutic interventions, such as relaxation techniques or trigger
identification.
2. Question: A nurse is caring for a client who is experiencing a panic
attack. Which of the following actions should the nurse take first?
A. Administer an anti-anxiety medication
B. Remain with the client and offer reassurance
C. Ask the client to describe their feelings
D. Encourage the client to take deep breaths
Answer: B. Remain with the client and offer reassurance
Rationale: During a panic attack, it is essential for the nurse to remain
with the client to offer reassurance and ensure safety. While other
actions like deep breathing or medications can be helpful, providing
emotional support and ensuring the client is not left alone is the
priority.
,3. Question: A nurse is caring for a client diagnosed with
schizophrenia. The client states, “The voices tell me that I’m not
allowed to leave the room.” Which response should the nurse
provide?
A. “Don’t worry, the voices are not real.”
B. “Can you describe the voices that you are hearing?”
C. “You don’t need to listen to the voices.”
D. “Let’s talk about how you feel about the voices you are hearing.”
Answer: B. “Can you describe the voices that you are hearing?”
Rationale: The nurse should focus on understanding the client’s
experience and establish trust. By asking the client to describe the
voices, the nurse encourages expression without invalidating the client’s
experience, which helps assess the severity of symptoms and provides
an opportunity for further intervention.
4. Question: A nurse is preparing to administer an antidepressant to a
client diagnosed with major depressive disorder. The nurse
understands that which of the following is a common side effect of
selective serotonin reuptake inhibitors (SSRIs)?
A. Weight gain
B. Dry mouth
C. Insomnia
D. Decreased libido
Answer: D. Decreased libido
Rationale: A common side effect of SSRIs is decreased libido. Clients
should be informed of this potential side effect so they can report any
, significant changes. While dry mouth and insomnia can occur,
decreased libido is one of the most commonly discussed and impactful
side effects of SSRIs.
5. Question: A nurse is teaching a client about the use of lithium to
manage bipolar disorder. Which of the following instructions should
the nurse include in the teaching?
A. “Increase your sodium intake while taking lithium.”
B. “Expect your urine output to decrease while on this medication.”
C. “Maintain a consistent level of fluid intake to avoid toxicity.”
D. “It’s okay to take lithium with caffeine in your diet.”
Answer: C. “Maintain a consistent level of fluid intake to avoid toxicity.”
Rationale: Lithium toxicity can occur if the client experiences
dehydration or changes in sodium levels, so it’s essential for clients to
maintain a consistent level of fluid intake. The nurse should educate the
client on the importance of staying hydrated and avoiding fluctuations
in fluid intake.
6. Question: A nurse is assessing a client diagnosed with borderline
personality disorder. Which of the following behaviors should the
nurse expect to observe?
A. Clear and stable relationships
B. Severe mood swings and impulsivity
C. Withdrawal from social interaction
D. Preoccupation with perfectionism
Answer: B. Severe mood swings and impulsivity
with generalized anxiety disorder (GAD). Which of the following is the
priority intervention?
A. Encourage the client to verbalize feelings
B. Establish a calm environment with minimal stimulation
C. Offer the client information about relaxation techniques
D. Assist the client with identifying triggers for anxiety
Answer: B. Establish a calm environment with minimal stimulation
Rationale: In clients with GAD, anxiety can be overwhelming, and a
calm environment helps to reduce external stressors and allows the
client to regain a sense of control. This is the priority intervention
because it ensures safety and creates a foundation for further
therapeutic interventions, such as relaxation techniques or trigger
identification.
2. Question: A nurse is caring for a client who is experiencing a panic
attack. Which of the following actions should the nurse take first?
A. Administer an anti-anxiety medication
B. Remain with the client and offer reassurance
C. Ask the client to describe their feelings
D. Encourage the client to take deep breaths
Answer: B. Remain with the client and offer reassurance
Rationale: During a panic attack, it is essential for the nurse to remain
with the client to offer reassurance and ensure safety. While other
actions like deep breathing or medications can be helpful, providing
emotional support and ensuring the client is not left alone is the
priority.
,3. Question: A nurse is caring for a client diagnosed with
schizophrenia. The client states, “The voices tell me that I’m not
allowed to leave the room.” Which response should the nurse
provide?
A. “Don’t worry, the voices are not real.”
B. “Can you describe the voices that you are hearing?”
C. “You don’t need to listen to the voices.”
D. “Let’s talk about how you feel about the voices you are hearing.”
Answer: B. “Can you describe the voices that you are hearing?”
Rationale: The nurse should focus on understanding the client’s
experience and establish trust. By asking the client to describe the
voices, the nurse encourages expression without invalidating the client’s
experience, which helps assess the severity of symptoms and provides
an opportunity for further intervention.
4. Question: A nurse is preparing to administer an antidepressant to a
client diagnosed with major depressive disorder. The nurse
understands that which of the following is a common side effect of
selective serotonin reuptake inhibitors (SSRIs)?
A. Weight gain
B. Dry mouth
C. Insomnia
D. Decreased libido
Answer: D. Decreased libido
Rationale: A common side effect of SSRIs is decreased libido. Clients
should be informed of this potential side effect so they can report any
, significant changes. While dry mouth and insomnia can occur,
decreased libido is one of the most commonly discussed and impactful
side effects of SSRIs.
5. Question: A nurse is teaching a client about the use of lithium to
manage bipolar disorder. Which of the following instructions should
the nurse include in the teaching?
A. “Increase your sodium intake while taking lithium.”
B. “Expect your urine output to decrease while on this medication.”
C. “Maintain a consistent level of fluid intake to avoid toxicity.”
D. “It’s okay to take lithium with caffeine in your diet.”
Answer: C. “Maintain a consistent level of fluid intake to avoid toxicity.”
Rationale: Lithium toxicity can occur if the client experiences
dehydration or changes in sodium levels, so it’s essential for clients to
maintain a consistent level of fluid intake. The nurse should educate the
client on the importance of staying hydrated and avoiding fluctuations
in fluid intake.
6. Question: A nurse is assessing a client diagnosed with borderline
personality disorder. Which of the following behaviors should the
nurse expect to observe?
A. Clear and stable relationships
B. Severe mood swings and impulsivity
C. Withdrawal from social interaction
D. Preoccupation with perfectionism
Answer: B. Severe mood swings and impulsivity
