, Question 1
A client with schizophrenia exhibits flat affect, avolition, and poverty of
speech. Which finding would the nurse recognize as evidence that a
second-generation antipsychotic is producing its intended therapeutic effect on
these symptoms?
A. Reduced intensity of auditory hallucinations
B. Improved initiation of self-care and social engagement
C. Decreased frequency of disorganized speech
D. Diminished paranoid delusional content
Correct Answer: B - Improved initiation of self-care and social
engagement
RATIONALE
Avolition, flat affect, and poverty of speech are negative symptoms;
improvement in initiation and social engagement reflects
negative-symptom response, which second-generation antipsychotics
preferentially target. Options A, C, and D describe positive symptoms
(hallucinations, disorganization, delusions) whose reduction does not
confirm negative-symptom improvement.
Question 2
During a mental status examination, a client states, 'The radio is broadcasting
my thoughts to the CIA.' The nurse should document this as which type of
thought disturbance?
A. Thought broadcasting
B. Thought insertion
C. Ideas of reference
D. Magical thinking
Correct Answer: A - Thought broadcasting
Page 2
, RATIONALE
Thought broadcasting is the delusional belief that one's thoughts are
being transmitted or made known to others, as described. Thought
insertion is the belief that external forces place thoughts into one's
mind; ideas of reference involve interpreting neutral events as
personally directed; magical thinking attributes causality to unrelated
thoughts or actions.
Question 3
A client receiving lithium carbonate reports coarse hand tremor, ataxia, and
vomiting. The serum lithium level is 2.1 mEq/L. Which nursing action takes
priority?
A. Administer the next scheduled lithium dose with food
B. Hold the lithium and notify the provider immediately
C. Encourage increased oral fluid intake and reassess in 4 hours
D. Document findings as expected side effects of therapy
Correct Answer: B - Hold the lithium and notify the provider
immediately
RATIONALE
A lithium level of 2.1 mEq/L with neurotoxicity and GI symptoms
indicates moderate-to-severe toxicity; the nurse must hold the drug
and notify the provider for possible hemodialysis. Continuing the dose
worsens toxicity; fluids alone are inadequate for this level; and these
are not expected side effects.
Question 4
Which nursing intervention best reflects the core principle of trauma-informed
care when a client becomes agitated during a psychiatric interview?
A. Move the client to a quiet area and offer choices about continuing the
discussion
B. Apply mechanical restraints to prevent escalation
Page 3
, C. Administer PRN haloperidol immediately
D. Ask the client to describe the original trauma in detail
Correct Answer: A - Move the client to a quiet area and offer
choices about continuing the discussion
RATIONALE
Trauma-informed care prioritizes safety, choice, and collaboration;
offering a calm environment and control over the interaction prevents
retraumatization. Restraints and involuntary medication are restrictive
last resorts, and probing trauma details can re-traumatize the client.
Question 5
A client with major depressive disorder has been taking sertraline for 3 weeks
and reports increased energy but persistent suicidal ideation. Which
phenomenon should the nurse recognize?
A. Serotonin syndrome
B. Activation syndrome with elevated suicide risk
C. Antidepressant discontinuation syndrome
D. Therapeutic remission of depression
Correct Answer: B - Activation syndrome with elevated suicide
risk
RATIONALE
Early antidepressant response can increase psychomotor energy before
mood fully improves, elevating suicide risk-an activation phenomenon
requiring close monitoring. Serotonin syndrome presents with
autonomic and neuromuscular signs; discontinuation syndrome
follows abrupt cessation; remission would include resolution of
suicidal ideation.
Page 4
A client with schizophrenia exhibits flat affect, avolition, and poverty of
speech. Which finding would the nurse recognize as evidence that a
second-generation antipsychotic is producing its intended therapeutic effect on
these symptoms?
A. Reduced intensity of auditory hallucinations
B. Improved initiation of self-care and social engagement
C. Decreased frequency of disorganized speech
D. Diminished paranoid delusional content
Correct Answer: B - Improved initiation of self-care and social
engagement
RATIONALE
Avolition, flat affect, and poverty of speech are negative symptoms;
improvement in initiation and social engagement reflects
negative-symptom response, which second-generation antipsychotics
preferentially target. Options A, C, and D describe positive symptoms
(hallucinations, disorganization, delusions) whose reduction does not
confirm negative-symptom improvement.
Question 2
During a mental status examination, a client states, 'The radio is broadcasting
my thoughts to the CIA.' The nurse should document this as which type of
thought disturbance?
A. Thought broadcasting
B. Thought insertion
C. Ideas of reference
D. Magical thinking
Correct Answer: A - Thought broadcasting
Page 2
, RATIONALE
Thought broadcasting is the delusional belief that one's thoughts are
being transmitted or made known to others, as described. Thought
insertion is the belief that external forces place thoughts into one's
mind; ideas of reference involve interpreting neutral events as
personally directed; magical thinking attributes causality to unrelated
thoughts or actions.
Question 3
A client receiving lithium carbonate reports coarse hand tremor, ataxia, and
vomiting. The serum lithium level is 2.1 mEq/L. Which nursing action takes
priority?
A. Administer the next scheduled lithium dose with food
B. Hold the lithium and notify the provider immediately
C. Encourage increased oral fluid intake and reassess in 4 hours
D. Document findings as expected side effects of therapy
Correct Answer: B - Hold the lithium and notify the provider
immediately
RATIONALE
A lithium level of 2.1 mEq/L with neurotoxicity and GI symptoms
indicates moderate-to-severe toxicity; the nurse must hold the drug
and notify the provider for possible hemodialysis. Continuing the dose
worsens toxicity; fluids alone are inadequate for this level; and these
are not expected side effects.
Question 4
Which nursing intervention best reflects the core principle of trauma-informed
care when a client becomes agitated during a psychiatric interview?
A. Move the client to a quiet area and offer choices about continuing the
discussion
B. Apply mechanical restraints to prevent escalation
Page 3
, C. Administer PRN haloperidol immediately
D. Ask the client to describe the original trauma in detail
Correct Answer: A - Move the client to a quiet area and offer
choices about continuing the discussion
RATIONALE
Trauma-informed care prioritizes safety, choice, and collaboration;
offering a calm environment and control over the interaction prevents
retraumatization. Restraints and involuntary medication are restrictive
last resorts, and probing trauma details can re-traumatize the client.
Question 5
A client with major depressive disorder has been taking sertraline for 3 weeks
and reports increased energy but persistent suicidal ideation. Which
phenomenon should the nurse recognize?
A. Serotonin syndrome
B. Activation syndrome with elevated suicide risk
C. Antidepressant discontinuation syndrome
D. Therapeutic remission of depression
Correct Answer: B - Activation syndrome with elevated suicide
risk
RATIONALE
Early antidepressant response can increase psychomotor energy before
mood fully improves, elevating suicide risk-an activation phenomenon
requiring close monitoring. Serotonin syndrome presents with
autonomic and neuromuscular signs; discontinuation syndrome
follows abrupt cessation; remission would include resolution of
suicidal ideation.
Page 4
