Question 1:
A nurse is working with a client diagnosed with major depressive
disorder. The client expresses feelings of hopelessness and states, "I
don't think I'll ever get better." Which of the following statements
should the nurse make?
A) "You need to stop thinking negatively."
B) "I'm sure you will feel better soon."
C) "It sounds like you're feeling very hopeless right now."
D) "You have been depressed for a while, so you need to be patient with
yourself."
Answer: C) "It sounds like you're feeling very hopeless right now."
Rationale:
The nurse's response demonstrates active listening and validates the
client's feelings without dismissing or minimizing them. It acknowledges
the client's emotional state and provides an opportunity for further
discussion, which is important in building a therapeutic relationship.
Question 2:
A client with schizophrenia is being discharged from the hospital and is
prescribed clozapine. The nurse should emphasize the importance of
which of the following during follow-up care?
A) Monthly blood tests to monitor for agranulocytosis.
B) Increasing fluid intake to prevent dehydration.
C) Avoiding sun exposure due to photosensitivity.
D) Reducing the dosage if tremors are noted.
Answer: A) Monthly blood tests to monitor for agranulocytosis.
,Rationale:
Clozapine is associated with the risk of agranulocytosis, a potentially
life-threatening condition involving a severe decrease in white blood
cells. Regular blood tests are necessary to monitor for this complication
and ensure the client’s safety while taking the medication.
Question 3:
A nurse is caring for a client with borderline personality disorder. Which
of the following behaviors is the client most likely to exhibit?
A) Difficulty maintaining stable relationships.
B) Pervasive mistrust of others.
C) Euphoria and excessive excitement.
D) Lack of interest in social interactions.
Answer: A) Difficulty maintaining stable relationships.
Rationale:
Clients with borderline personality disorder often experience instability
in their relationships, self-image, and emotions. This results in frequent
shifts between idealizing and devaluing others, which leads to
difficulties in maintaining stable relationships.
Question 4:
A client with bipolar disorder is prescribed lithium. The nurse should
monitor the client for which of the following signs of lithium toxicity?
A) Weight gain and edema.
B) Hand tremors and confusion.
C) Increased appetite and hyperactivity.
D) Frequent urination and dry mouth.
,Answer: B) Hand tremors and confusion.
Rationale:
Lithium toxicity can present with symptoms such as hand tremors,
confusion, and ataxia. It is important to monitor lithium levels and
recognize signs of toxicity to prevent serious complications such as
seizures or renal failure.
Question 5:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following interventions is the most appropriate to help the
client manage anxiety?
A) Encourage the client to avoid discussing stressful situations.
B) Promote relaxation techniques such as deep breathing exercises.
C) Suggest that the client engage in activities that increase anxiety.
D) Focus on the past to identify the cause of anxiety.
Answer: B) Promote relaxation techniques such as deep breathing
exercises.
Rationale:
Relaxation techniques, such as deep breathing, progressive muscle
relaxation, or mindfulness, are effective in managing anxiety. These
interventions help reduce the physical symptoms of anxiety and
promote a sense of calm and control.
Question 6:
A nurse is assessing a client who has been diagnosed with post-
traumatic stress disorder (PTSD). Which of the following symptoms
should the nurse expect to find?
, A) Hypervigilance and exaggerated startle response.
B) Lack of interest in activities once enjoyed.
C) Decreased appetite and weight loss.
D) Episodes of extreme euphoria.
Answer: A) Hypervigilance and exaggerated startle response.
Rationale:
Hypervigilance and exaggerated startle response are common
symptoms of PTSD. These symptoms reflect heightened anxiety and fear
due to a perceived threat or trauma. The other symptoms are more
characteristic of depression or mood disorders.
Question 7:
A nurse is caring for a client who has been prescribed a selective
serotonin reuptake inhibitor (SSRI) for depression. The nurse should
monitor the client for which of the following adverse effects?
A) Insomnia and dry mouth.
B) Sedation and hypotension.
C) Increased appetite and weight gain.
D) Sexual dysfunction and gastrointestinal upset.
Answer: D) Sexual dysfunction and gastrointestinal upset.
Rationale:
SSRIs commonly cause sexual dysfunction (e.g., decreased libido,
difficulty achieving orgasm) and gastrointestinal symptoms (e.g.,
nausea, diarrhea). These side effects are important to monitor and may
require further intervention or medication adjustment.
Question 8:
A nurse is working with a client diagnosed with major depressive
disorder. The client expresses feelings of hopelessness and states, "I
don't think I'll ever get better." Which of the following statements
should the nurse make?
A) "You need to stop thinking negatively."
B) "I'm sure you will feel better soon."
C) "It sounds like you're feeling very hopeless right now."
D) "You have been depressed for a while, so you need to be patient with
yourself."
Answer: C) "It sounds like you're feeling very hopeless right now."
Rationale:
The nurse's response demonstrates active listening and validates the
client's feelings without dismissing or minimizing them. It acknowledges
the client's emotional state and provides an opportunity for further
discussion, which is important in building a therapeutic relationship.
Question 2:
A client with schizophrenia is being discharged from the hospital and is
prescribed clozapine. The nurse should emphasize the importance of
which of the following during follow-up care?
A) Monthly blood tests to monitor for agranulocytosis.
B) Increasing fluid intake to prevent dehydration.
C) Avoiding sun exposure due to photosensitivity.
D) Reducing the dosage if tremors are noted.
Answer: A) Monthly blood tests to monitor for agranulocytosis.
,Rationale:
Clozapine is associated with the risk of agranulocytosis, a potentially
life-threatening condition involving a severe decrease in white blood
cells. Regular blood tests are necessary to monitor for this complication
and ensure the client’s safety while taking the medication.
Question 3:
A nurse is caring for a client with borderline personality disorder. Which
of the following behaviors is the client most likely to exhibit?
A) Difficulty maintaining stable relationships.
B) Pervasive mistrust of others.
C) Euphoria and excessive excitement.
D) Lack of interest in social interactions.
Answer: A) Difficulty maintaining stable relationships.
Rationale:
Clients with borderline personality disorder often experience instability
in their relationships, self-image, and emotions. This results in frequent
shifts between idealizing and devaluing others, which leads to
difficulties in maintaining stable relationships.
Question 4:
A client with bipolar disorder is prescribed lithium. The nurse should
monitor the client for which of the following signs of lithium toxicity?
A) Weight gain and edema.
B) Hand tremors and confusion.
C) Increased appetite and hyperactivity.
D) Frequent urination and dry mouth.
,Answer: B) Hand tremors and confusion.
Rationale:
Lithium toxicity can present with symptoms such as hand tremors,
confusion, and ataxia. It is important to monitor lithium levels and
recognize signs of toxicity to prevent serious complications such as
seizures or renal failure.
Question 5:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following interventions is the most appropriate to help the
client manage anxiety?
A) Encourage the client to avoid discussing stressful situations.
B) Promote relaxation techniques such as deep breathing exercises.
C) Suggest that the client engage in activities that increase anxiety.
D) Focus on the past to identify the cause of anxiety.
Answer: B) Promote relaxation techniques such as deep breathing
exercises.
Rationale:
Relaxation techniques, such as deep breathing, progressive muscle
relaxation, or mindfulness, are effective in managing anxiety. These
interventions help reduce the physical symptoms of anxiety and
promote a sense of calm and control.
Question 6:
A nurse is assessing a client who has been diagnosed with post-
traumatic stress disorder (PTSD). Which of the following symptoms
should the nurse expect to find?
, A) Hypervigilance and exaggerated startle response.
B) Lack of interest in activities once enjoyed.
C) Decreased appetite and weight loss.
D) Episodes of extreme euphoria.
Answer: A) Hypervigilance and exaggerated startle response.
Rationale:
Hypervigilance and exaggerated startle response are common
symptoms of PTSD. These symptoms reflect heightened anxiety and fear
due to a perceived threat or trauma. The other symptoms are more
characteristic of depression or mood disorders.
Question 7:
A nurse is caring for a client who has been prescribed a selective
serotonin reuptake inhibitor (SSRI) for depression. The nurse should
monitor the client for which of the following adverse effects?
A) Insomnia and dry mouth.
B) Sedation and hypotension.
C) Increased appetite and weight gain.
D) Sexual dysfunction and gastrointestinal upset.
Answer: D) Sexual dysfunction and gastrointestinal upset.
Rationale:
SSRIs commonly cause sexual dysfunction (e.g., decreased libido,
difficulty achieving orgasm) and gastrointestinal symptoms (e.g.,
nausea, diarrhea). These side effects are important to monitor and may
require further intervention or medication adjustment.
Question 8:
