1. A client is being treated for depression. The nurse notices that the
client is withdrawing from social interactions and has a lack of
motivation. Which of the following actions is the nurse's priority?
a) Encourage the client to participate in social activities
b) Involve the client in the planning of daily activities
c) Assess the client's current level of depression
d) Administer prescribed antidepressant medication
Answer: c) Assess the client's current level of depression
Rationale: The priority action is to assess the client’s current mental
health status and level of depression. This will provide essential
information to guide further interventions. Understanding the severity
of the depression is crucial before attempting to encourage social
interaction or activities.
2. A nurse is teaching a group of clients about managing anxiety.
Which of the following techniques is most likely to help clients
manage anxiety?
a) Encourage clients to suppress anxious feelings
b) Teach clients to practice deep breathing exercises
c) Instruct clients to avoid all stressful situations
d) Suggest that clients avoid discussing their anxiety
Answer: b) Teach clients to practice deep breathing exercises
Rationale: Deep breathing exercises help reduce the physiological
symptoms of anxiety by promoting relaxation and slowing the heart
rate. It is an effective coping strategy to manage anxiety and is
commonly used in therapeutic interventions.
,3. A client who has been diagnosed with schizophrenia is experiencing
auditory hallucinations. The nurse should:
a) Argue with the client to prove that the hallucinations are not real
b) Ignore the hallucinations and focus on reality-based conversations
c) Encourage the client to discuss the content of the hallucinations
d) Offer reassurance that the hallucinations will go away soon
Answer: c) Encourage the client to discuss the content of the
hallucinations
Rationale: Encouraging the client to talk about the hallucinations helps
to provide emotional support, validate the experience, and allows the
nurse to assess the client's perception of reality. It is important not to
argue or dismiss the hallucinations.
4. A client with bipolar disorder is experiencing a manic episode. The
nurse should implement which of the following interventions?
a) Allow the client to make decisions without setting boundaries
b) Encourage the client to engage in physical activities to expend energy
c) Set firm limits on the client’s behavior and maintain consistency
d) Provide an environment with minimal stimulation to promote
relaxation
Answer: c) Set firm limits on the client’s behavior and maintain
consistency
Rationale: During a manic episode, setting firm boundaries is essential
to prevent risky or harmful behaviors. Consistency in interventions
helps manage the client's behavior and provides a structure that can
reduce agitation.
, 5. A client with obsessive-compulsive disorder (OCD) is asking the
nurse if they can engage in their compulsive ritual of hand-washing.
What is the nurse’s best response?
a) "You should stop the ritual, as it is not helping your condition."
b) "It is important to reduce your hand-washing ritual gradually."
c) "You can wash your hands, but only for a shorter time than usual."
d) "Let’s find a healthier way to express your anxiety."
Answer: b) "It is important to reduce your hand-washing ritual
gradually."
Rationale: Gradual reduction of compulsive rituals is the most effective
approach in treating OCD. Abruptly stopping rituals can increase
anxiety, so a gradual approach that involves reducing the behavior over
time is preferred.
6. A nurse is caring for a client who is taking lithium for bipolar
disorder. The nurse should monitor the client for which of the
following adverse effects?
a) Hyperkalemia
b) Weight loss
c) Tinnitus
d) Tremors
Answer: d) Tremors
Rationale: A common side effect of lithium therapy is tremors. Other
side effects may include weight gain, polyuria, and hypothyroidism.
Tinnitus is not typically associated with lithium, while hyperkalemia is
not a common side effect.
client is withdrawing from social interactions and has a lack of
motivation. Which of the following actions is the nurse's priority?
a) Encourage the client to participate in social activities
b) Involve the client in the planning of daily activities
c) Assess the client's current level of depression
d) Administer prescribed antidepressant medication
Answer: c) Assess the client's current level of depression
Rationale: The priority action is to assess the client’s current mental
health status and level of depression. This will provide essential
information to guide further interventions. Understanding the severity
of the depression is crucial before attempting to encourage social
interaction or activities.
2. A nurse is teaching a group of clients about managing anxiety.
Which of the following techniques is most likely to help clients
manage anxiety?
a) Encourage clients to suppress anxious feelings
b) Teach clients to practice deep breathing exercises
c) Instruct clients to avoid all stressful situations
d) Suggest that clients avoid discussing their anxiety
Answer: b) Teach clients to practice deep breathing exercises
Rationale: Deep breathing exercises help reduce the physiological
symptoms of anxiety by promoting relaxation and slowing the heart
rate. It is an effective coping strategy to manage anxiety and is
commonly used in therapeutic interventions.
,3. A client who has been diagnosed with schizophrenia is experiencing
auditory hallucinations. The nurse should:
a) Argue with the client to prove that the hallucinations are not real
b) Ignore the hallucinations and focus on reality-based conversations
c) Encourage the client to discuss the content of the hallucinations
d) Offer reassurance that the hallucinations will go away soon
Answer: c) Encourage the client to discuss the content of the
hallucinations
Rationale: Encouraging the client to talk about the hallucinations helps
to provide emotional support, validate the experience, and allows the
nurse to assess the client's perception of reality. It is important not to
argue or dismiss the hallucinations.
4. A client with bipolar disorder is experiencing a manic episode. The
nurse should implement which of the following interventions?
a) Allow the client to make decisions without setting boundaries
b) Encourage the client to engage in physical activities to expend energy
c) Set firm limits on the client’s behavior and maintain consistency
d) Provide an environment with minimal stimulation to promote
relaxation
Answer: c) Set firm limits on the client’s behavior and maintain
consistency
Rationale: During a manic episode, setting firm boundaries is essential
to prevent risky or harmful behaviors. Consistency in interventions
helps manage the client's behavior and provides a structure that can
reduce agitation.
, 5. A client with obsessive-compulsive disorder (OCD) is asking the
nurse if they can engage in their compulsive ritual of hand-washing.
What is the nurse’s best response?
a) "You should stop the ritual, as it is not helping your condition."
b) "It is important to reduce your hand-washing ritual gradually."
c) "You can wash your hands, but only for a shorter time than usual."
d) "Let’s find a healthier way to express your anxiety."
Answer: b) "It is important to reduce your hand-washing ritual
gradually."
Rationale: Gradual reduction of compulsive rituals is the most effective
approach in treating OCD. Abruptly stopping rituals can increase
anxiety, so a gradual approach that involves reducing the behavior over
time is preferred.
6. A nurse is caring for a client who is taking lithium for bipolar
disorder. The nurse should monitor the client for which of the
following adverse effects?
a) Hyperkalemia
b) Weight loss
c) Tinnitus
d) Tremors
Answer: d) Tremors
Rationale: A common side effect of lithium therapy is tremors. Other
side effects may include weight gain, polyuria, and hypothyroidism.
Tinnitus is not typically associated with lithium, while hyperkalemia is
not a common side effect.
