1. A nurse is caring for a client who is experiencing a panic attack.
Which of the following interventions is the nurse's priority?
A) Encourage the client to take deep breaths
B) Encourage the client to identify the trigger for the attack
C) Provide a quiet and safe environment for the client
D) Ask the client to verbalize their feelings
Answer: C) Provide a quiet and safe environment for the client
Rationale: The priority intervention during a panic attack is to ensure
the client is in a quiet, safe environment. This reduces external stimuli,
which can help decrease the severity of the attack. Encouraging deep
breathing (A) and identifying triggers (B) are secondary interventions.
Asking the client to verbalize feelings (D) may not be appropriate during
an acute panic episode.
2. A nurse is caring for a client who has schizophrenia and is
experiencing auditory hallucinations. The client states, "The voices
are telling me to hurt myself." Which of the following is the nurse's
priority action?
A) Encourage the client to ignore the voices
B) Ask the client about their current suicidal thoughts and intent
C) Offer reassurance and tell the client the voices are not real
D) Distract the client by providing an engaging activity
Answer: B) Ask the client about their current suicidal thoughts and
intent
Rationale: The priority action is to assess for safety, specifically
suicidal ideation and intent, as the client may be at risk of harm.
Offering reassurance (C) is not sufficient when the client is at risk for
,self-harm. Ignoring the voices (A) or distracting the client (D) may not
address the immediate safety concerns.
3. A nurse is preparing to administer fluoxetine (Prozac) to a client
with major depressive disorder. Which of the following client
statements indicates the need for further teaching?
A) "I should take this medication in the morning."
B) "I may experience some dry mouth while on this medication."
C) "It will take a few weeks for this medication to work."
D) "I can stop this medication whenever I feel better."
Answer: D) "I can stop this medication whenever I feel better."
Rationale: Clients should be informed that antidepressants like
fluoxetine require consistent use for several weeks to see full effects.
Discontinuing the medication abruptly may lead to withdrawal
symptoms or relapse of depression. The other statements (A, B, C) are
appropriate.
4. A nurse is caring for a client with bipolar disorder who is
experiencing a manic episode. Which of the following interventions
is most appropriate for this client?
A) Allow the client to make decisions about their activities
B) Provide structured activities to help the client focus
C) Encourage the client to engage in group therapy
D) Allow the client to sleep as much as they want
Answer: B) Provide structured activities to help the client focus
Rationale: Clients in a manic episode often have excessive energy and
difficulty focusing. Providing structured activities helps direct their
, energy and maintain safety. Allowing the client to make decisions (A)
could lead to poor choices. Group therapy (C) may not be appropriate
during a manic episode. Allowing excessive sleep (D) could interfere
with their schedule and disrupt treatment.
5. A nurse is caring for a client with generalized anxiety disorder
(GAD). The nurse should anticipate that the client will report which
of the following symptoms?
A) Delusions and hallucinations
B) Difficulty concentrating and restlessness
C) Decreased appetite and weight loss
D) Extreme fear of specific objects or situations
Answer: B) Difficulty concentrating and restlessness
Rationale: Clients with GAD commonly report symptoms like
restlessness, difficulty concentrating, and excessive worry. Delusions
and hallucinations (A) are more common in psychotic disorders.
Decreased appetite (C) and extreme fears (D) are more indicative of
other disorders, such as anorexia or phobias.
6. A nurse is caring for a client who is receiving lithium therapy.
Which of the following laboratory results should the nurse report
immediately to the healthcare provider?
A) Blood urea nitrogen (BUN) level of 12 mg/dL
B) Serum sodium level of 138 mEq/L
C) Serum lithium level of 1.8 mEq/L
D) Serum creatinine level of 0.8 mg/dL
Answer: C) Serum lithium level of 1.8 mEq/L
Which of the following interventions is the nurse's priority?
A) Encourage the client to take deep breaths
B) Encourage the client to identify the trigger for the attack
C) Provide a quiet and safe environment for the client
D) Ask the client to verbalize their feelings
Answer: C) Provide a quiet and safe environment for the client
Rationale: The priority intervention during a panic attack is to ensure
the client is in a quiet, safe environment. This reduces external stimuli,
which can help decrease the severity of the attack. Encouraging deep
breathing (A) and identifying triggers (B) are secondary interventions.
Asking the client to verbalize feelings (D) may not be appropriate during
an acute panic episode.
2. A nurse is caring for a client who has schizophrenia and is
experiencing auditory hallucinations. The client states, "The voices
are telling me to hurt myself." Which of the following is the nurse's
priority action?
A) Encourage the client to ignore the voices
B) Ask the client about their current suicidal thoughts and intent
C) Offer reassurance and tell the client the voices are not real
D) Distract the client by providing an engaging activity
Answer: B) Ask the client about their current suicidal thoughts and
intent
Rationale: The priority action is to assess for safety, specifically
suicidal ideation and intent, as the client may be at risk of harm.
Offering reassurance (C) is not sufficient when the client is at risk for
,self-harm. Ignoring the voices (A) or distracting the client (D) may not
address the immediate safety concerns.
3. A nurse is preparing to administer fluoxetine (Prozac) to a client
with major depressive disorder. Which of the following client
statements indicates the need for further teaching?
A) "I should take this medication in the morning."
B) "I may experience some dry mouth while on this medication."
C) "It will take a few weeks for this medication to work."
D) "I can stop this medication whenever I feel better."
Answer: D) "I can stop this medication whenever I feel better."
Rationale: Clients should be informed that antidepressants like
fluoxetine require consistent use for several weeks to see full effects.
Discontinuing the medication abruptly may lead to withdrawal
symptoms or relapse of depression. The other statements (A, B, C) are
appropriate.
4. A nurse is caring for a client with bipolar disorder who is
experiencing a manic episode. Which of the following interventions
is most appropriate for this client?
A) Allow the client to make decisions about their activities
B) Provide structured activities to help the client focus
C) Encourage the client to engage in group therapy
D) Allow the client to sleep as much as they want
Answer: B) Provide structured activities to help the client focus
Rationale: Clients in a manic episode often have excessive energy and
difficulty focusing. Providing structured activities helps direct their
, energy and maintain safety. Allowing the client to make decisions (A)
could lead to poor choices. Group therapy (C) may not be appropriate
during a manic episode. Allowing excessive sleep (D) could interfere
with their schedule and disrupt treatment.
5. A nurse is caring for a client with generalized anxiety disorder
(GAD). The nurse should anticipate that the client will report which
of the following symptoms?
A) Delusions and hallucinations
B) Difficulty concentrating and restlessness
C) Decreased appetite and weight loss
D) Extreme fear of specific objects or situations
Answer: B) Difficulty concentrating and restlessness
Rationale: Clients with GAD commonly report symptoms like
restlessness, difficulty concentrating, and excessive worry. Delusions
and hallucinations (A) are more common in psychotic disorders.
Decreased appetite (C) and extreme fears (D) are more indicative of
other disorders, such as anorexia or phobias.
6. A nurse is caring for a client who is receiving lithium therapy.
Which of the following laboratory results should the nurse report
immediately to the healthcare provider?
A) Blood urea nitrogen (BUN) level of 12 mg/dL
B) Serum sodium level of 138 mEq/L
C) Serum lithium level of 1.8 mEq/L
D) Serum creatinine level of 0.8 mg/dL
Answer: C) Serum lithium level of 1.8 mEq/L
