1. A nurse is caring for a client diagnosed with major depressive
disorder (MDD). Which of the following is the priority intervention for
the nurse to take?
a) Encourage the client to express feelings
b) Promote socialization with other clients
c) Provide a structured environment
d) Teach the client relaxation techniques
Answer: c) Provide a structured environment
Rationale: Clients with MDD may have difficulty focusing, making
decisions, and maintaining activities. Providing a structured
environment can help reduce feelings of confusion and enhance the
sense of safety. While encouraging expression of feelings, promoting
socialization, and teaching relaxation techniques are important, these
are secondary to providing structure for the client’s well-being.
2. A nurse is caring for a client with schizophrenia who is exhibiting
command hallucinations. The nurse should:
a) Ask the client if they hear voices
b) Distract the client with a calm, structured activity
c) Ignore the hallucinations and continue with the plan of care
d) Reassure the client that the hallucinations are not real
Answer: b) Distract the client with a calm, structured activity
Rationale: For clients with schizophrenia, especially those experiencing
command hallucinations, it’s essential to focus on reality-based
interventions. Distracting the client with a structured activity helps
reduce the intensity of the hallucinations. Ignoring or denying the
hallucinations can escalate anxiety or fear.
,3. A client who is receiving lithium therapy for bipolar disorder is
admitted for dehydration. Which laboratory result is the nurse's
priority to assess?
a) Sodium level
b) Lithium level
c) Blood urea nitrogen (BUN)
d) Potassium level
Answer: b) Lithium level
Rationale: Dehydration can cause an increase in lithium levels, leading
to toxicity. The nurse should assess the lithium level first. While sodium
and potassium levels are important, lithium toxicity is the priority
concern with dehydration.
4. A nurse is teaching a client about the side effects of tricyclic
antidepressants (TCAs). Which of the following should the nurse
include in the teaching?
a) Increased libido
b) Blurred vision
c) Weight loss
d) Insomnia
Answer: b) Blurred vision
Rationale: TCAs can cause anticholinergic effects, including blurred
vision, dry mouth, constipation, and urinary retention. Weight gain, not
loss, and sedation rather than insomnia are more commonly seen with
TCAs.
, 5. A nurse is assessing a client with generalized anxiety disorder
(GAD). Which of the following is the most common physical
manifestation of anxiety in this disorder?
a) Sleep disturbances
b) Heart palpitations
c) Nausea
d) Chest pain
Answer: b) Heart palpitations
Rationale: Clients with GAD often experience physiological
manifestations of anxiety, such as heart palpitations, muscle tension,
and restlessness. While sleep disturbances, nausea, and chest pain can
occur, palpitations are a hallmark of anxiety disorders.
6. A nurse is caring for a client receiving electroconvulsive therapy
(ECT). Which of the following is an expected side effect after the
procedure?
a) Loss of appetite
b) Temporary memory loss
c) Increased energy
d) Persistent headaches
Answer: b) Temporary memory loss
Rationale: Memory loss, especially short-term, is a common side effect
following ECT. This is typically temporary and resolves within a few
weeks. Loss of appetite, increased energy, and persistent headaches are
not expected after the procedure.
disorder (MDD). Which of the following is the priority intervention for
the nurse to take?
a) Encourage the client to express feelings
b) Promote socialization with other clients
c) Provide a structured environment
d) Teach the client relaxation techniques
Answer: c) Provide a structured environment
Rationale: Clients with MDD may have difficulty focusing, making
decisions, and maintaining activities. Providing a structured
environment can help reduce feelings of confusion and enhance the
sense of safety. While encouraging expression of feelings, promoting
socialization, and teaching relaxation techniques are important, these
are secondary to providing structure for the client’s well-being.
2. A nurse is caring for a client with schizophrenia who is exhibiting
command hallucinations. The nurse should:
a) Ask the client if they hear voices
b) Distract the client with a calm, structured activity
c) Ignore the hallucinations and continue with the plan of care
d) Reassure the client that the hallucinations are not real
Answer: b) Distract the client with a calm, structured activity
Rationale: For clients with schizophrenia, especially those experiencing
command hallucinations, it’s essential to focus on reality-based
interventions. Distracting the client with a structured activity helps
reduce the intensity of the hallucinations. Ignoring or denying the
hallucinations can escalate anxiety or fear.
,3. A client who is receiving lithium therapy for bipolar disorder is
admitted for dehydration. Which laboratory result is the nurse's
priority to assess?
a) Sodium level
b) Lithium level
c) Blood urea nitrogen (BUN)
d) Potassium level
Answer: b) Lithium level
Rationale: Dehydration can cause an increase in lithium levels, leading
to toxicity. The nurse should assess the lithium level first. While sodium
and potassium levels are important, lithium toxicity is the priority
concern with dehydration.
4. A nurse is teaching a client about the side effects of tricyclic
antidepressants (TCAs). Which of the following should the nurse
include in the teaching?
a) Increased libido
b) Blurred vision
c) Weight loss
d) Insomnia
Answer: b) Blurred vision
Rationale: TCAs can cause anticholinergic effects, including blurred
vision, dry mouth, constipation, and urinary retention. Weight gain, not
loss, and sedation rather than insomnia are more commonly seen with
TCAs.
, 5. A nurse is assessing a client with generalized anxiety disorder
(GAD). Which of the following is the most common physical
manifestation of anxiety in this disorder?
a) Sleep disturbances
b) Heart palpitations
c) Nausea
d) Chest pain
Answer: b) Heart palpitations
Rationale: Clients with GAD often experience physiological
manifestations of anxiety, such as heart palpitations, muscle tension,
and restlessness. While sleep disturbances, nausea, and chest pain can
occur, palpitations are a hallmark of anxiety disorders.
6. A nurse is caring for a client receiving electroconvulsive therapy
(ECT). Which of the following is an expected side effect after the
procedure?
a) Loss of appetite
b) Temporary memory loss
c) Increased energy
d) Persistent headaches
Answer: b) Temporary memory loss
Rationale: Memory loss, especially short-term, is a common side effect
following ECT. This is typically temporary and resolves within a few
weeks. Loss of appetite, increased energy, and persistent headaches are
not expected after the procedure.
