1. A nurse is caring for a client with schizophrenia. Which of the
following is the most important nursing intervention?
A. Encourage the client to participate in group therapy
B. Monitor the client’s vital signs regularly
C. Ensure the client is taking prescribed antipsychotic medication
D. Provide a calm and structured environment
Answer: D. Provide a calm and structured environment
Rationale: Clients with schizophrenia often benefit from a calm,
structured environment as it helps reduce anxiety, confusion, and the
likelihood of psychotic episodes. Regular medication administration and
therapy are important but providing a stable environment is crucial.
2. A nurse is assessing a client diagnosed with bipolar disorder
during a manic episode. Which of the following behaviors would the
nurse most likely observe?
A. Decreased energy and withdrawal from social interactions
B. Rapid speech, racing thoughts, and increased physical activity
C. Difficulty sleeping and loss of appetite
D. Increased need for sleep and weight gain
Answer: B. Rapid speech, racing thoughts, and increased physical
activity
Rationale: During a manic episode in bipolar disorder, clients exhibit
symptoms like rapid speech (pressured speech), racing thoughts, and
hyperactivity. These symptoms are indicative of elevated mood and
energy levels.
,3. A client with depression is prescribed an antidepressant. Which of
the following is an appropriate teaching point for the nurse to
include?
A. “You may begin to feel better immediately after starting the
medication.”
B. “It may take several weeks before you feel the full effects of the
medication.”
C. “You should avoid all dairy products while taking this medication.”
D. “Do not drink alcohol while on this medication as it can make the
medication more effective.”
Answer: B. “It may take several weeks before you feel the full effects of
the medication.”
Rationale: Antidepressants typically take several weeks to reach their
full therapeutic effect. Clients should be informed of this delayed onset
to manage expectations and encourage adherence.
4. A nurse is caring for a client diagnosed with borderline
personality disorder (BPD). Which of the following behaviors would
the nurse most likely observe?
A. Grandiosity and a sense of entitlement
B. Intense, unstable relationships and fear of abandonment
C. Difficulty making decisions and a lack of self-confidence
D. Pervasive distrust and suspicion of others
Answer: B. Intense, unstable relationships and fear of abandonment
Rationale: Borderline personality disorder is characterized by emotional
instability, unstable interpersonal relationships, and a fear of
abandonment. Clients with BPD may engage in splitting behavior,
idealizing or devaluing others.
, 5. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following interventions would be most
appropriate to implement?
A. Encourage the client to avoid discussing the traumatic event
B. Promote physical exercise to reduce symptoms of anxiety
C. Facilitate opportunities for the client to talk about the trauma at their
own pace
D. Teach the client to suppress their feelings of fear and anxiety
Answer: C. Facilitate opportunities for the client to talk about the
trauma at their own pace
Rationale: One of the therapeutic interventions for PTSD is trauma-
focused therapy, where clients are encouraged to talk about the traumatic
event at their own pace. Avoiding or suppressing the trauma may
increase distress.
6. A nurse is caring for a client diagnosed with anorexia nervosa.
The nurse should be most concerned about which of the following?
A. Weight loss of 5 pounds in the past week
B. Low body mass index (BMI) and electrolyte imbalances
C. The client refusing to eat meals in the dining room
D. The client expressing desire to engage in therapy
Answer: B. Low body mass index (BMI) and electrolyte imbalances
Rationale: A dangerously low BMI and electrolyte imbalances,
particularly low potassium levels, are critical concerns in anorexia
nervosa and can lead to life-threatening conditions such as cardiac arrest.
following is the most important nursing intervention?
A. Encourage the client to participate in group therapy
B. Monitor the client’s vital signs regularly
C. Ensure the client is taking prescribed antipsychotic medication
D. Provide a calm and structured environment
Answer: D. Provide a calm and structured environment
Rationale: Clients with schizophrenia often benefit from a calm,
structured environment as it helps reduce anxiety, confusion, and the
likelihood of psychotic episodes. Regular medication administration and
therapy are important but providing a stable environment is crucial.
2. A nurse is assessing a client diagnosed with bipolar disorder
during a manic episode. Which of the following behaviors would the
nurse most likely observe?
A. Decreased energy and withdrawal from social interactions
B. Rapid speech, racing thoughts, and increased physical activity
C. Difficulty sleeping and loss of appetite
D. Increased need for sleep and weight gain
Answer: B. Rapid speech, racing thoughts, and increased physical
activity
Rationale: During a manic episode in bipolar disorder, clients exhibit
symptoms like rapid speech (pressured speech), racing thoughts, and
hyperactivity. These symptoms are indicative of elevated mood and
energy levels.
,3. A client with depression is prescribed an antidepressant. Which of
the following is an appropriate teaching point for the nurse to
include?
A. “You may begin to feel better immediately after starting the
medication.”
B. “It may take several weeks before you feel the full effects of the
medication.”
C. “You should avoid all dairy products while taking this medication.”
D. “Do not drink alcohol while on this medication as it can make the
medication more effective.”
Answer: B. “It may take several weeks before you feel the full effects of
the medication.”
Rationale: Antidepressants typically take several weeks to reach their
full therapeutic effect. Clients should be informed of this delayed onset
to manage expectations and encourage adherence.
4. A nurse is caring for a client diagnosed with borderline
personality disorder (BPD). Which of the following behaviors would
the nurse most likely observe?
A. Grandiosity and a sense of entitlement
B. Intense, unstable relationships and fear of abandonment
C. Difficulty making decisions and a lack of self-confidence
D. Pervasive distrust and suspicion of others
Answer: B. Intense, unstable relationships and fear of abandonment
Rationale: Borderline personality disorder is characterized by emotional
instability, unstable interpersonal relationships, and a fear of
abandonment. Clients with BPD may engage in splitting behavior,
idealizing or devaluing others.
, 5. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following interventions would be most
appropriate to implement?
A. Encourage the client to avoid discussing the traumatic event
B. Promote physical exercise to reduce symptoms of anxiety
C. Facilitate opportunities for the client to talk about the trauma at their
own pace
D. Teach the client to suppress their feelings of fear and anxiety
Answer: C. Facilitate opportunities for the client to talk about the
trauma at their own pace
Rationale: One of the therapeutic interventions for PTSD is trauma-
focused therapy, where clients are encouraged to talk about the traumatic
event at their own pace. Avoiding or suppressing the trauma may
increase distress.
6. A nurse is caring for a client diagnosed with anorexia nervosa.
The nurse should be most concerned about which of the following?
A. Weight loss of 5 pounds in the past week
B. Low body mass index (BMI) and electrolyte imbalances
C. The client refusing to eat meals in the dining room
D. The client expressing desire to engage in therapy
Answer: B. Low body mass index (BMI) and electrolyte imbalances
Rationale: A dangerously low BMI and electrolyte imbalances,
particularly low potassium levels, are critical concerns in anorexia
nervosa and can lead to life-threatening conditions such as cardiac arrest.
