1. A nurse is caring for a client who has a new diagnosis of major
depressive disorder (MDD). Which of the following findings is the
most significant indicator of the client’s risk for suicide?
A) The client reports feelings of hopelessness. B) The client has a history
of substance abuse. C) The client has a family history of depression. D)
The client has a lack of social support.
Answer: A) The client reports feelings of hopelessness.
Rationale: Hopelessness is a major risk factor for suicide in individuals
with depression. It reflects a belief that things will never improve and
can lead to suicidal thoughts or behaviors. While substance abuse,
family history of depression, and lack of social support also contribute
to the risk, hopelessness is the most significant indicator.
2. A nurse is providing teaching to a client who is prescribed lithium
for the treatment of bipolar disorder. Which of the following
statements by the client indicates the need for further teaching?
A) "I should take my medication at the same time every day." B) "I need
to increase my fluid intake to at least 2-3 liters a day." C) "I should avoid
eating foods with high sodium content." D) "I can stop taking the
medication if I feel fine."
Answer: D) "I can stop taking the medication if I feel fine."
Rationale: Clients with bipolar disorder should not stop taking lithium
abruptly, even if they feel better. Discontinuing the medication can lead
to a relapse or destabilization of mood. Continuous medication is
necessary for long-term management of bipolar disorder.
,3. A nurse is caring for a client who is experiencing a panic attack.
Which of the following actions should the nurse take first?
A) Encourage the client to take slow, deep breaths. B) Have the client
drink a glass of water. C) Ask the client to describe their feelings. D) Stay
with the client and provide reassurance.
Answer: D) Stay with the client and provide reassurance.
Rationale: The priority intervention for a client experiencing a panic
attack is to stay with them and provide reassurance. This helps to
establish safety and reduce anxiety. Encouraging slow, deep breaths and
asking the client to describe feelings are also helpful, but reassurance is
the immediate priority.
4. A nurse is assessing a client who has posttraumatic stress disorder
(PTSD). Which of the following findings should the nurse expect?
A) Excessive worry and tension. B) Intrusive memories and flashbacks.
C) Apathy and indifference. D) Difficulty maintaining attention.
Answer: B) Intrusive memories and flashbacks.
Rationale: PTSD is characterized by intrusive memories, flashbacks, and
nightmares related to a traumatic event. These symptoms are often
triggered by reminders of the trauma. Excessive worry and tension are
more indicative of generalized anxiety disorder (GAD), and apathy is not
a primary feature of PTSD.
5. A nurse is caring for a client who is taking a selective serotonin
reuptake inhibitor (SSRI) for depression. The client reports feeling
restless, agitated, and having muscle rigidity. Which of the following is
the nurse’s priority action?
, A) Administer a dose of benzodiazepine. B) Withhold the next dose of
the SSRI. C) Assess the client for signs of serotonin syndrome. D)
Encourage the client to increase fluid intake.
Answer: C) Assess the client for signs of serotonin syndrome.
Rationale: The client’s symptoms (restlessness, agitation, muscle
rigidity) are indicative of serotonin syndrome, a potentially life-
threatening condition caused by excessive serotonin in the brain. The
nurse should assess for other symptoms, such as hyperthermia and
autonomic dysfunction, and immediately report findings to the
provider.
6. A nurse is providing discharge teaching for a client who is diagnosed
with schizophrenia and prescribed clozapine. Which of the following
statements by the client indicates the need for further teaching?
A) "I will get my blood checked regularly." B) "I may experience dizziness
when standing up quickly." C) "I should avoid eating foods high in
vitamin K." D) "I should contact my healthcare provider if I develop a
sore throat."
Answer: C) "I should avoid eating foods high in vitamin K."
Rationale: Clozapine does not require dietary restrictions related to
vitamin K. However, regular blood monitoring is necessary because
clozapine can cause agranulocytosis, a condition that reduces white
blood cells and increases the risk of infection. The client should also be
aware of the risk for orthostatic hypotension and should report any
signs of infection, such as a sore throat.
depressive disorder (MDD). Which of the following findings is the
most significant indicator of the client’s risk for suicide?
A) The client reports feelings of hopelessness. B) The client has a history
of substance abuse. C) The client has a family history of depression. D)
The client has a lack of social support.
Answer: A) The client reports feelings of hopelessness.
Rationale: Hopelessness is a major risk factor for suicide in individuals
with depression. It reflects a belief that things will never improve and
can lead to suicidal thoughts or behaviors. While substance abuse,
family history of depression, and lack of social support also contribute
to the risk, hopelessness is the most significant indicator.
2. A nurse is providing teaching to a client who is prescribed lithium
for the treatment of bipolar disorder. Which of the following
statements by the client indicates the need for further teaching?
A) "I should take my medication at the same time every day." B) "I need
to increase my fluid intake to at least 2-3 liters a day." C) "I should avoid
eating foods with high sodium content." D) "I can stop taking the
medication if I feel fine."
Answer: D) "I can stop taking the medication if I feel fine."
Rationale: Clients with bipolar disorder should not stop taking lithium
abruptly, even if they feel better. Discontinuing the medication can lead
to a relapse or destabilization of mood. Continuous medication is
necessary for long-term management of bipolar disorder.
,3. A nurse is caring for a client who is experiencing a panic attack.
Which of the following actions should the nurse take first?
A) Encourage the client to take slow, deep breaths. B) Have the client
drink a glass of water. C) Ask the client to describe their feelings. D) Stay
with the client and provide reassurance.
Answer: D) Stay with the client and provide reassurance.
Rationale: The priority intervention for a client experiencing a panic
attack is to stay with them and provide reassurance. This helps to
establish safety and reduce anxiety. Encouraging slow, deep breaths and
asking the client to describe feelings are also helpful, but reassurance is
the immediate priority.
4. A nurse is assessing a client who has posttraumatic stress disorder
(PTSD). Which of the following findings should the nurse expect?
A) Excessive worry and tension. B) Intrusive memories and flashbacks.
C) Apathy and indifference. D) Difficulty maintaining attention.
Answer: B) Intrusive memories and flashbacks.
Rationale: PTSD is characterized by intrusive memories, flashbacks, and
nightmares related to a traumatic event. These symptoms are often
triggered by reminders of the trauma. Excessive worry and tension are
more indicative of generalized anxiety disorder (GAD), and apathy is not
a primary feature of PTSD.
5. A nurse is caring for a client who is taking a selective serotonin
reuptake inhibitor (SSRI) for depression. The client reports feeling
restless, agitated, and having muscle rigidity. Which of the following is
the nurse’s priority action?
, A) Administer a dose of benzodiazepine. B) Withhold the next dose of
the SSRI. C) Assess the client for signs of serotonin syndrome. D)
Encourage the client to increase fluid intake.
Answer: C) Assess the client for signs of serotonin syndrome.
Rationale: The client’s symptoms (restlessness, agitation, muscle
rigidity) are indicative of serotonin syndrome, a potentially life-
threatening condition caused by excessive serotonin in the brain. The
nurse should assess for other symptoms, such as hyperthermia and
autonomic dysfunction, and immediately report findings to the
provider.
6. A nurse is providing discharge teaching for a client who is diagnosed
with schizophrenia and prescribed clozapine. Which of the following
statements by the client indicates the need for further teaching?
A) "I will get my blood checked regularly." B) "I may experience dizziness
when standing up quickly." C) "I should avoid eating foods high in
vitamin K." D) "I should contact my healthcare provider if I develop a
sore throat."
Answer: C) "I should avoid eating foods high in vitamin K."
Rationale: Clozapine does not require dietary restrictions related to
vitamin K. However, regular blood monitoring is necessary because
clozapine can cause agranulocytosis, a condition that reduces white
blood cells and increases the risk of infection. The client should also be
aware of the risk for orthostatic hypotension and should report any
signs of infection, such as a sore throat.
