1. A nurse is caring for a client who is experiencing severe anxiety.
Which of the following actions should the nurse take first?
A) Administer prescribed anti-anxiety medication.
B) Encourage the client to talk about their feelings.
C) Establish a calm environment.
D) Use relaxation techniques with the client.
Answer: C) Establish a calm environment.
Rationale: The first priority when caring for a client with severe anxiety
is to ensure a calm and safe environment. This helps reduce external
stimuli, which can exacerbate anxiety. After the environment is stable,
other interventions such as medication, talking, and relaxation
techniques can be considered.
2. A client with depression states, “I don’t feel like I’m worth
anything.” Which response by the nurse is therapeutic?
A) “You’re just going through a rough patch. Things will get better.”
B) “I’m sorry you feel that way, but I assure you that you have worth.”
C) “You’re not worthless. You’re a valuable person, and we care about
you.”
D) “You are not alone in this. I’m here to help you through it.”
Answer: D) “You are not alone in this. I’m here to help you through it.”
Rationale: This response is therapeutic because it conveys support and
encourages the client to feel understood and not alone. Offering
empathy and reinforcing the therapeutic relationship can help the client
feel more secure.
,3. A nurse is assessing a client who is at risk for suicide. Which of the
following statements by the client indicates the highest risk for
suicide?
A) “I’m really struggling right now, but I have people who care about
me.”
B) “I think I would be better off if I weren’t here anymore.”
C) “I’m planning to take a break from my responsibilities for a while.”
D) “Sometimes I think about ending it all, but I know that’s not the right
choice.”
Answer: B) “I think I would be better off if I weren’t here anymore.”
Rationale: This statement indicates a clear expression of suicidal
ideation and is the most concerning. Clients who express thoughts
about not wanting to be alive or feeling they would be better off dead
require immediate intervention to assess the risk of suicide and ensure
safety.
4. A nurse is caring for a client diagnosed with schizophrenia. Which of
the following is the best approach to help the client manage auditory
hallucinations?
A) Tell the client to ignore the voices and distract themselves.
B) Encourage the client to talk to the voices to understand them better.
C) Validate the client’s experience and explain the voices are a symptom
of their illness.
D) Provide loud music to drown out the voices.
Answer: C) Validate the client’s experience and explain the voices are
a symptom of their illness.
, Rationale: It is important to acknowledge the client’s experience of
auditory hallucinations, as this helps build trust. Explaining that the
voices are a symptom of their illness can reduce the client's anxiety
about the experience, while maintaining a therapeutic relationship.
5. A nurse is teaching a client about the use of selective serotonin
reuptake inhibitors (SSRIs) for depression. Which of the following
statements by the client indicates understanding of the teaching?
A) “I can stop taking the medication as soon as I feel better.”
B) “It may take several weeks before I notice an improvement in my
symptoms.”
C) “I need to take this medication on an empty stomach for the best
effect.”
D) “This medication can be stopped abruptly if I experience side
effects.”
Answer: B) “It may take several weeks before I notice an improvement
in my symptoms.”
Rationale: SSRIs typically take 2-4 weeks to begin showing therapeutic
effects. Clients should be educated about this to help manage their
expectations. Stopping the medication abruptly can cause withdrawal
symptoms, and the medication should be taken with food to reduce
gastrointestinal discomfort.
6. A nurse is caring for a client diagnosed with bipolar disorder. The
client is experiencing a manic episode. Which of the following
interventions should the nurse implement first?
Which of the following actions should the nurse take first?
A) Administer prescribed anti-anxiety medication.
B) Encourage the client to talk about their feelings.
C) Establish a calm environment.
D) Use relaxation techniques with the client.
Answer: C) Establish a calm environment.
Rationale: The first priority when caring for a client with severe anxiety
is to ensure a calm and safe environment. This helps reduce external
stimuli, which can exacerbate anxiety. After the environment is stable,
other interventions such as medication, talking, and relaxation
techniques can be considered.
2. A client with depression states, “I don’t feel like I’m worth
anything.” Which response by the nurse is therapeutic?
A) “You’re just going through a rough patch. Things will get better.”
B) “I’m sorry you feel that way, but I assure you that you have worth.”
C) “You’re not worthless. You’re a valuable person, and we care about
you.”
D) “You are not alone in this. I’m here to help you through it.”
Answer: D) “You are not alone in this. I’m here to help you through it.”
Rationale: This response is therapeutic because it conveys support and
encourages the client to feel understood and not alone. Offering
empathy and reinforcing the therapeutic relationship can help the client
feel more secure.
,3. A nurse is assessing a client who is at risk for suicide. Which of the
following statements by the client indicates the highest risk for
suicide?
A) “I’m really struggling right now, but I have people who care about
me.”
B) “I think I would be better off if I weren’t here anymore.”
C) “I’m planning to take a break from my responsibilities for a while.”
D) “Sometimes I think about ending it all, but I know that’s not the right
choice.”
Answer: B) “I think I would be better off if I weren’t here anymore.”
Rationale: This statement indicates a clear expression of suicidal
ideation and is the most concerning. Clients who express thoughts
about not wanting to be alive or feeling they would be better off dead
require immediate intervention to assess the risk of suicide and ensure
safety.
4. A nurse is caring for a client diagnosed with schizophrenia. Which of
the following is the best approach to help the client manage auditory
hallucinations?
A) Tell the client to ignore the voices and distract themselves.
B) Encourage the client to talk to the voices to understand them better.
C) Validate the client’s experience and explain the voices are a symptom
of their illness.
D) Provide loud music to drown out the voices.
Answer: C) Validate the client’s experience and explain the voices are
a symptom of their illness.
, Rationale: It is important to acknowledge the client’s experience of
auditory hallucinations, as this helps build trust. Explaining that the
voices are a symptom of their illness can reduce the client's anxiety
about the experience, while maintaining a therapeutic relationship.
5. A nurse is teaching a client about the use of selective serotonin
reuptake inhibitors (SSRIs) for depression. Which of the following
statements by the client indicates understanding of the teaching?
A) “I can stop taking the medication as soon as I feel better.”
B) “It may take several weeks before I notice an improvement in my
symptoms.”
C) “I need to take this medication on an empty stomach for the best
effect.”
D) “This medication can be stopped abruptly if I experience side
effects.”
Answer: B) “It may take several weeks before I notice an improvement
in my symptoms.”
Rationale: SSRIs typically take 2-4 weeks to begin showing therapeutic
effects. Clients should be educated about this to help manage their
expectations. Stopping the medication abruptly can cause withdrawal
symptoms, and the medication should be taken with food to reduce
gastrointestinal discomfort.
6. A nurse is caring for a client diagnosed with bipolar disorder. The
client is experiencing a manic episode. Which of the following
interventions should the nurse implement first?
