Question 1:
A nurse is caring for a client who is diagnosed with depression. Which of
the following actions should the nurse take to establish trust with the
client?
A. Avoid speaking to the client until they initiate conversation.
B. Sit silently beside the client for a short period.
C. Ask the client direct questions about their personal life.
D. Encourage the client to engage in group activities.
Answer: B. Sit silently beside the client for a short period.
Rationale: Clients with depression may be reluctant to engage in
conversation. Sitting silently beside the client provides a non-
threatening presence, which helps establish trust and comfort. Direct
questioning or pushing for engagement may feel invasive to the client,
which can hinder trust-building.
Question 2:
A client with schizophrenia is experiencing auditory hallucinations.
Which of the following interventions should the nurse prioritize?
A. Disregard the hallucinations and provide distractions.
B. Remind the client that the hallucinations are not real.
C. Ask the client to describe the voices they are hearing.
D. Encourage the client to focus on a reality-based task.
Answer: C. Ask the client to describe the voices they are hearing.
Rationale: It is important to understand the content and nature of the
hallucinations to provide appropriate care. Asking the client to describe
the voices helps to assess the severity and type of hallucination, guiding
,further interventions. Disregarding or minimizing the hallucinations can
make the client feel misunderstood.
Question 3:
A nurse is caring for a client who has been diagnosed with generalized
anxiety disorder. Which of the following strategies should the nurse
implement to assist the client in managing anxiety?
A. Encourage the client to avoid all stressors.
B. Teach the client relaxation techniques.
C. Advise the client to suppress anxious thoughts.
D. Tell the client to take deep breaths and count to 10.
Answer: B. Teach the client relaxation techniques.
Rationale: Teaching relaxation techniques, such as deep breathing,
progressive muscle relaxation, or guided imagery, helps the client
reduce anxiety symptoms and gain control over their response to stress.
Avoiding stressors is not a sustainable long-term strategy, and
suppressing anxious thoughts can increase anxiety.
Question 4:
A nurse is preparing to discharge a client with bipolar disorder who is
stable on medication. Which of the following instructions should the
nurse include in the discharge teaching?
A. “It is okay to stop taking your medication if you feel well.”
B. “You should avoid all sources of stress in your life.”
C. “It is important to monitor your mood for any signs of change.”
D. “You should sleep at least 12 hours a night to manage symptoms.”
, Answer: C. “It is important to monitor your mood for any signs of
change.”
Rationale: Clients with bipolar disorder must monitor their mood for
any signs of mania or depression, as early intervention can help prevent
relapse. Stopping medication without consulting a healthcare provider
can lead to a relapse of symptoms, and avoiding stress or excessive
sleep is not a practical solution for managing the disorder.
Question 5:
A nurse is caring for a client who is receiving electroconvulsive therapy
(ECT) for severe depression. Which of the following is the nurse’s
priority after the procedure?
A. Offer the client a snack to restore blood sugar levels.
B. Assess the client’s level of consciousness and orientation.
C. Provide emotional support and encourage the client to talk.
D. Administer pain medication as prescribed.
Answer: B. Assess the client’s level of consciousness and orientation.
Rationale: After ECT, clients may experience confusion or memory loss,
so assessing their level of consciousness and orientation is crucial.
Offering a snack or providing emotional support may be important later,
but the priority is to monitor for any immediate post-procedure
complications.
Question 6:
A nurse is caring for a client who has a history of alcohol use disorder
and is currently in withdrawal. Which of the following findings should
the nurse report immediately?
A nurse is caring for a client who is diagnosed with depression. Which of
the following actions should the nurse take to establish trust with the
client?
A. Avoid speaking to the client until they initiate conversation.
B. Sit silently beside the client for a short period.
C. Ask the client direct questions about their personal life.
D. Encourage the client to engage in group activities.
Answer: B. Sit silently beside the client for a short period.
Rationale: Clients with depression may be reluctant to engage in
conversation. Sitting silently beside the client provides a non-
threatening presence, which helps establish trust and comfort. Direct
questioning or pushing for engagement may feel invasive to the client,
which can hinder trust-building.
Question 2:
A client with schizophrenia is experiencing auditory hallucinations.
Which of the following interventions should the nurse prioritize?
A. Disregard the hallucinations and provide distractions.
B. Remind the client that the hallucinations are not real.
C. Ask the client to describe the voices they are hearing.
D. Encourage the client to focus on a reality-based task.
Answer: C. Ask the client to describe the voices they are hearing.
Rationale: It is important to understand the content and nature of the
hallucinations to provide appropriate care. Asking the client to describe
the voices helps to assess the severity and type of hallucination, guiding
,further interventions. Disregarding or minimizing the hallucinations can
make the client feel misunderstood.
Question 3:
A nurse is caring for a client who has been diagnosed with generalized
anxiety disorder. Which of the following strategies should the nurse
implement to assist the client in managing anxiety?
A. Encourage the client to avoid all stressors.
B. Teach the client relaxation techniques.
C. Advise the client to suppress anxious thoughts.
D. Tell the client to take deep breaths and count to 10.
Answer: B. Teach the client relaxation techniques.
Rationale: Teaching relaxation techniques, such as deep breathing,
progressive muscle relaxation, or guided imagery, helps the client
reduce anxiety symptoms and gain control over their response to stress.
Avoiding stressors is not a sustainable long-term strategy, and
suppressing anxious thoughts can increase anxiety.
Question 4:
A nurse is preparing to discharge a client with bipolar disorder who is
stable on medication. Which of the following instructions should the
nurse include in the discharge teaching?
A. “It is okay to stop taking your medication if you feel well.”
B. “You should avoid all sources of stress in your life.”
C. “It is important to monitor your mood for any signs of change.”
D. “You should sleep at least 12 hours a night to manage symptoms.”
, Answer: C. “It is important to monitor your mood for any signs of
change.”
Rationale: Clients with bipolar disorder must monitor their mood for
any signs of mania or depression, as early intervention can help prevent
relapse. Stopping medication without consulting a healthcare provider
can lead to a relapse of symptoms, and avoiding stress or excessive
sleep is not a practical solution for managing the disorder.
Question 5:
A nurse is caring for a client who is receiving electroconvulsive therapy
(ECT) for severe depression. Which of the following is the nurse’s
priority after the procedure?
A. Offer the client a snack to restore blood sugar levels.
B. Assess the client’s level of consciousness and orientation.
C. Provide emotional support and encourage the client to talk.
D. Administer pain medication as prescribed.
Answer: B. Assess the client’s level of consciousness and orientation.
Rationale: After ECT, clients may experience confusion or memory loss,
so assessing their level of consciousness and orientation is crucial.
Offering a snack or providing emotional support may be important later,
but the priority is to monitor for any immediate post-procedure
complications.
Question 6:
A nurse is caring for a client who has a history of alcohol use disorder
and is currently in withdrawal. Which of the following findings should
the nurse report immediately?
