1. Question:
A nurse is planning care for a client with major depressive disorder.
Which of the following interventions should the nurse prioritize?
A) Providing opportunities for the client to express feelings B)
Encouraging physical activity C) Giving the client a strict routine to
follow D) Implementing suicide precautions
Answer: D) Implementing suicide precautions
Rationale: For clients with major depressive disorder, suicide
precautions are a priority because of the risk for self-harm. While
expressing feelings and physical activity are important interventions,
ensuring the client's safety is paramount. Establishing a strict routine is
useful but not the most critical intervention.
2. Question:
A client with schizophrenia tells the nurse, "The voices are telling me to
hurt myself." Which of the following is the nurse's priority action?
A) Inform the client that the voices are not real B) Ask the client if they
have a plan to harm themselves C) Reassure the client that they will be
safe in the hospital D) Administer the client’s prescribed antipsychotic
medication
Answer: B) Ask the client if they have a plan to harm themselves
Rationale: When a client with schizophrenia expresses thoughts of self-
harm, the priority is to assess the risk for suicide or self-injury.
Understanding if the client has a plan helps the nurse to determine the
level of risk and take appropriate action. Reassurance, medication, and
dismissing the voices are not the immediate interventions.
,3. Question:
A nurse is caring for a client who is experiencing a panic attack. Which
of the following is the best nursing intervention?
A) Encourage the client to engage in conversation B) Reassure the client
that the panic attack will soon pass C) Guide the client through deep-
breathing exercises D) Tell the client to relax and try to regain control
Answer: C) Guide the client through deep-breathing exercises
Rationale: During a panic attack, the best intervention is to help the
client focus on calming techniques, such as deep-breathing exercises, to
reduce the intensity of the symptoms. Encouraging conversation or
telling the client to relax may be overwhelming and ineffective during a
panic attack.
4. Question:
A nurse is assessing a client with generalized anxiety disorder. Which of
the following is a common manifestation of this disorder?
A) Extreme fear of social situations B) Persistent worry and tension C)
Difficulty maintaining attention D) Hallucinations and delusions
Answer: B) Persistent worry and tension
Rationale: Generalized anxiety disorder is characterized by excessive
and persistent worry and tension, often without a clear cause. While
other disorders may involve fear (social anxiety) or cognitive issues
(attention), the hallmark symptom of generalized anxiety disorder is
chronic worry.
, 5. Question:
A client with borderline personality disorder has been exhibiting
impulsive behaviors, such as gambling and substance use. Which of the
following is the nurse's most appropriate response?
A) "You need to stop these behaviors immediately." B) "Let’s talk about
why you engage in these behaviors." C) "I will call your therapist to
discuss this behavior." D) "It’s important to focus on your therapy and
not on impulsive behaviors."
Answer: B) "Let’s talk about why you engage in these behaviors."
Rationale: Clients with borderline personality disorder often engage in
impulsive behaviors as a way to cope with emotional dysregulation. The
most therapeutic approach is to explore the reasons behind these
behaviors in order to identify patterns and address underlying issues.
Simply stopping the behavior or focusing only on therapy does not
address the emotional needs driving the behavior.
6. Question:
A nurse is teaching a client with bipolar disorder about the use of
lithium. Which of the following statements by the client indicates a
need for further teaching?
A) "I should drink plenty of fluids while taking lithium." B) "I will have
regular blood tests to check my lithium levels." C) "If I gain weight, I will
stop taking the medication." D) "I should avoid activities that could lead
to dehydration."
Answer: C) "If I gain weight, I will stop taking the medication."
Rationale: Lithium is used to treat bipolar disorder, and weight gain is a
common side effect. However, stopping the medication due to weight
A nurse is planning care for a client with major depressive disorder.
Which of the following interventions should the nurse prioritize?
A) Providing opportunities for the client to express feelings B)
Encouraging physical activity C) Giving the client a strict routine to
follow D) Implementing suicide precautions
Answer: D) Implementing suicide precautions
Rationale: For clients with major depressive disorder, suicide
precautions are a priority because of the risk for self-harm. While
expressing feelings and physical activity are important interventions,
ensuring the client's safety is paramount. Establishing a strict routine is
useful but not the most critical intervention.
2. Question:
A client with schizophrenia tells the nurse, "The voices are telling me to
hurt myself." Which of the following is the nurse's priority action?
A) Inform the client that the voices are not real B) Ask the client if they
have a plan to harm themselves C) Reassure the client that they will be
safe in the hospital D) Administer the client’s prescribed antipsychotic
medication
Answer: B) Ask the client if they have a plan to harm themselves
Rationale: When a client with schizophrenia expresses thoughts of self-
harm, the priority is to assess the risk for suicide or self-injury.
Understanding if the client has a plan helps the nurse to determine the
level of risk and take appropriate action. Reassurance, medication, and
dismissing the voices are not the immediate interventions.
,3. Question:
A nurse is caring for a client who is experiencing a panic attack. Which
of the following is the best nursing intervention?
A) Encourage the client to engage in conversation B) Reassure the client
that the panic attack will soon pass C) Guide the client through deep-
breathing exercises D) Tell the client to relax and try to regain control
Answer: C) Guide the client through deep-breathing exercises
Rationale: During a panic attack, the best intervention is to help the
client focus on calming techniques, such as deep-breathing exercises, to
reduce the intensity of the symptoms. Encouraging conversation or
telling the client to relax may be overwhelming and ineffective during a
panic attack.
4. Question:
A nurse is assessing a client with generalized anxiety disorder. Which of
the following is a common manifestation of this disorder?
A) Extreme fear of social situations B) Persistent worry and tension C)
Difficulty maintaining attention D) Hallucinations and delusions
Answer: B) Persistent worry and tension
Rationale: Generalized anxiety disorder is characterized by excessive
and persistent worry and tension, often without a clear cause. While
other disorders may involve fear (social anxiety) or cognitive issues
(attention), the hallmark symptom of generalized anxiety disorder is
chronic worry.
, 5. Question:
A client with borderline personality disorder has been exhibiting
impulsive behaviors, such as gambling and substance use. Which of the
following is the nurse's most appropriate response?
A) "You need to stop these behaviors immediately." B) "Let’s talk about
why you engage in these behaviors." C) "I will call your therapist to
discuss this behavior." D) "It’s important to focus on your therapy and
not on impulsive behaviors."
Answer: B) "Let’s talk about why you engage in these behaviors."
Rationale: Clients with borderline personality disorder often engage in
impulsive behaviors as a way to cope with emotional dysregulation. The
most therapeutic approach is to explore the reasons behind these
behaviors in order to identify patterns and address underlying issues.
Simply stopping the behavior or focusing only on therapy does not
address the emotional needs driving the behavior.
6. Question:
A nurse is teaching a client with bipolar disorder about the use of
lithium. Which of the following statements by the client indicates a
need for further teaching?
A) "I should drink plenty of fluids while taking lithium." B) "I will have
regular blood tests to check my lithium levels." C) "If I gain weight, I will
stop taking the medication." D) "I should avoid activities that could lead
to dehydration."
Answer: C) "If I gain weight, I will stop taking the medication."
Rationale: Lithium is used to treat bipolar disorder, and weight gain is a
common side effect. However, stopping the medication due to weight
