1. 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) Encourage the client to take slow, deep breaths.
B) Offer the client a glass of water.
C) Ask the client to identify the source of the anxiety.
D) Encourage the client to engage in physical activity.
Answer: A) Encourage the client to take slow, deep breaths.
Rationale: During a panic attack, the priority is to help the client regain
control of their breathing to prevent hyperventilation. Deep breathing
exercises help to reduce the intensity of the panic attack and lower
physiological arousal. Offering water or engaging in physical activity
might not address the immediate need to calm the client. Identifying
the source of anxiety is not helpful during a panic attack because the
client may be too overwhelmed to think clearly.
2. Question:
A nurse is providing teaching to a client with generalized anxiety
disorder (GAD). Which of the following strategies should the nurse
include in the teaching?
A) Use alcohol as a way to manage stress.
B) Practice relaxation techniques such as deep breathing and
meditation.
C) Avoid exposure to anxiety-provoking situations.
D) Focus on the worst-case scenario to anticipate problems.
Answer: B) Practice relaxation techniques such as deep breathing and
meditation.
,Rationale: Relaxation techniques such as deep breathing and
meditation help clients with GAD manage anxiety and reduce the
physical symptoms of anxiety. Avoiding situations or focusing on worst-
case scenarios can reinforce avoidance behaviors and increase anxiety.
Alcohol use is contraindicated as it can increase anxiety and interfere
with treatment.
3. Question:
A nurse is caring for a client diagnosed with schizophrenia. The client
says, "The government is watching me through my television." Which of
the following is the most appropriate response?
A) "That’s not possible. The government cannot watch you through your
television."
B) "I understand you're feeling like this, but I want to reassure you that
the television cannot transmit information."
C) "Why do you think the government is watching you?"
D) "Don't worry, there is nothing to fear from the government."
Answer: B) "I understand you're feeling like this, but I want to reassure
you that the television cannot transmit information."
Rationale: The nurse should validate the client’s feelings while
providing reality-based reassurance. It is important not to argue or
challenge the delusion directly, as this can cause further distress. The
goal is to provide comfort and reassurance without reinforcing the
delusion.
4. Question:
, A client with a history of depression and alcohol use disorder is
prescribed disulfiram (Antabuse). The nurse should provide which of
the following instructions to the client?
A) "You should avoid drinking alcohol for at least 12 hours after taking
disulfiram."
B) "It is safe to drink alcohol in moderation while taking disulfiram."
C) "If you drink alcohol, you may experience nausea, vomiting, and
headaches."
D) "You must take disulfiram with food to prevent nausea."
Answer: C) "If you drink alcohol, you may experience nausea, vomiting,
and headaches."
Rationale: Disulfiram causes a severe reaction when alcohol is
consumed, including nausea, vomiting, and headaches. This reaction is
meant to deter clients from drinking. It is essential for the nurse to
educate the client about this severe consequence to promote
compliance and prevent alcohol consumption while on disulfiram.
5. Question:
A nurse is assessing a client with major depressive disorder. Which of
the following findings should the nurse recognize as a priority to report
to the healthcare provider?
A) A client expresses feelings of hopelessness.
B) The client refuses to participate in group therapy.
C) The client states, "I have been sleeping too much."
D) The client has thoughts of self-harm.
Answer: D) The client has thoughts of self-harm.
A nurse is caring for a client who is experiencing a panic attack. Which
of the following actions should the nurse take first?
A) Encourage the client to take slow, deep breaths.
B) Offer the client a glass of water.
C) Ask the client to identify the source of the anxiety.
D) Encourage the client to engage in physical activity.
Answer: A) Encourage the client to take slow, deep breaths.
Rationale: During a panic attack, the priority is to help the client regain
control of their breathing to prevent hyperventilation. Deep breathing
exercises help to reduce the intensity of the panic attack and lower
physiological arousal. Offering water or engaging in physical activity
might not address the immediate need to calm the client. Identifying
the source of anxiety is not helpful during a panic attack because the
client may be too overwhelmed to think clearly.
2. Question:
A nurse is providing teaching to a client with generalized anxiety
disorder (GAD). Which of the following strategies should the nurse
include in the teaching?
A) Use alcohol as a way to manage stress.
B) Practice relaxation techniques such as deep breathing and
meditation.
C) Avoid exposure to anxiety-provoking situations.
D) Focus on the worst-case scenario to anticipate problems.
Answer: B) Practice relaxation techniques such as deep breathing and
meditation.
,Rationale: Relaxation techniques such as deep breathing and
meditation help clients with GAD manage anxiety and reduce the
physical symptoms of anxiety. Avoiding situations or focusing on worst-
case scenarios can reinforce avoidance behaviors and increase anxiety.
Alcohol use is contraindicated as it can increase anxiety and interfere
with treatment.
3. Question:
A nurse is caring for a client diagnosed with schizophrenia. The client
says, "The government is watching me through my television." Which of
the following is the most appropriate response?
A) "That’s not possible. The government cannot watch you through your
television."
B) "I understand you're feeling like this, but I want to reassure you that
the television cannot transmit information."
C) "Why do you think the government is watching you?"
D) "Don't worry, there is nothing to fear from the government."
Answer: B) "I understand you're feeling like this, but I want to reassure
you that the television cannot transmit information."
Rationale: The nurse should validate the client’s feelings while
providing reality-based reassurance. It is important not to argue or
challenge the delusion directly, as this can cause further distress. The
goal is to provide comfort and reassurance without reinforcing the
delusion.
4. Question:
, A client with a history of depression and alcohol use disorder is
prescribed disulfiram (Antabuse). The nurse should provide which of
the following instructions to the client?
A) "You should avoid drinking alcohol for at least 12 hours after taking
disulfiram."
B) "It is safe to drink alcohol in moderation while taking disulfiram."
C) "If you drink alcohol, you may experience nausea, vomiting, and
headaches."
D) "You must take disulfiram with food to prevent nausea."
Answer: C) "If you drink alcohol, you may experience nausea, vomiting,
and headaches."
Rationale: Disulfiram causes a severe reaction when alcohol is
consumed, including nausea, vomiting, and headaches. This reaction is
meant to deter clients from drinking. It is essential for the nurse to
educate the client about this severe consequence to promote
compliance and prevent alcohol consumption while on disulfiram.
5. Question:
A nurse is assessing a client with major depressive disorder. Which of
the following findings should the nurse recognize as a priority to report
to the healthcare provider?
A) A client expresses feelings of hopelessness.
B) The client refuses to participate in group therapy.
C) The client states, "I have been sleeping too much."
D) The client has thoughts of self-harm.
Answer: D) The client has thoughts of self-harm.
