Question 2: Therapeutic Communication
,A client tells the nurse, “Nobody cares about me, and my life is meaningless.” Which response
demonstrates therapeutic communication?
A. “You should not think so negatively.” B. “Other people have problems worse than yours.” C.
“Tell me more about what has been making you feel this way.” D. “You will feel better once you
leave the hospital.”
Correct Answer: C. “Tell me more about what has been making you feel this way.”
Rationale: Open-ended statements encourage clients to express their feelings and help the
nurse understand their concerns. Responses A and B minimize the client's emotions, while D
offers false reassurance without assessing the situation.
Question 3: Suicide Risk Assessment
A client admitted with major depressive disorder says, “I have decided to end my life tonight.”
What should the nurse do first?
A. Encourage the client to attend a recreational activity. B. Ask directly about the suicide plan,
access to means, and immediate intent while ensuring safety. C. Tell the client that suicide is
never the answer. D. Leave the client alone to allow time for reflection.
Correct Answer: B. Ask directly about the suicide plan, access to means, and immediate intent
while ensuring safety.
Rationale: A specific statement about suicide indicates potentially imminent danger. The nurse
should assess immediate risk, maintain observation appropriate to the level of danger, remove
accessible hazards, and promptly notify the responsible clinical team. Leaving the client alone or
relying on reassurance can increase risk. Directly asking about suicide does not create suicidal
thoughts.
Question 4: Major Depressive Disorder
Which finding is most characteristic of major depressive disorder?
A. Persistent elevated mood and decreased need for sleep. B. Recurrent hallucinations without
mood changes. C. Persistent depressed mood or loss of interest accompanied by other
depressive symptoms. D. Brief anxiety before public speaking.
Correct Answer: C. Persistent depressed mood or loss of interest accompanied by other
depressive symptoms.
Rationale: Major depressive disorder involves depressed mood or diminished interest or
pleasure, alongside additional symptoms such as sleep disturbance, appetite changes, fatigue,
impaired concentration, feelings of worthlessness, or suicidal thoughts. Symptoms generally
,persist for at least two weeks and cause clinically significant distress or impairment. Mania is
more characteristic of bipolar disorder, while brief situational anxiety alone does not establish
major depression.
Question 5: Bipolar Disorder — Acute Mania
A client experiencing acute mania is speaking rapidly, sleeping very little, and attempting to
participate in several activities simultaneously. Which nursing intervention is most appropriate?
A. Encourage participation in competitive group activities. B. Provide a low-stimulation
environment and establish clear, consistent limits. C. Challenge every unrealistic statement
made by the client. D. Encourage the client to make major financial decisions while energetic.
Correct Answer: B. Provide a low-stimulation environment and establish clear, consistent limits.
Rationale: Mania can cause impulsivity, poor judgment, excessive activity, and reduced sleep. A
quiet environment, simple directions, consistent boundaries, adequate hydration and nutrition,
and protection from risky behavior promote safety. Competitive or highly stimulating activities
may worsen agitation. Major financial and other consequential decisions should be postponed
when judgment is impaired.
Question 6: Schizophrenia — Auditory Hallucinations
A client with schizophrenia tells the nurse, “I hear voices saying I am worthless.” Which
response is best?
A. “The voices are real, and you should obey them.” B. “I do not hear the voices, but I
understand that they feel real to you. Are they telling you to hurt yourself or anyone else?” C.
“Stop imagining things.” D. “Why are you making up these stories?”
Correct Answer: B. “I do not hear the voices, but I understand that they feel real to you. Are
they telling you to hurt yourself or anyone else?”
Rationale: The nurse should acknowledge the client's experience without confirming the
hallucination as reality. Asking about harmful commands helps assess immediate safety.
Dismissing or ridiculing the client damages trust, while agreeing with the hallucination
reinforces the false perception.
Question 7: Delusions
A client believes that hospital staff have implanted a tracking device inside their body. Which
response is most therapeutic?
, A. “That is ridiculous; no one would do that.” B. “I know the staff are tracking you.” C. “I
understand that this feels frightening. I do not have evidence that a device has been implanted.”
D. “You should stop thinking about it.”
Correct Answer: C. “I understand that this feels frightening. I do not have evidence that a device
has been implanted.”
Rationale: The nurse should recognize the client's distress while presenting reality calmly.
Arguing aggressively can increase defensiveness, while agreeing with the delusion reinforces the
belief. The nurse should assess related fears, behavior, and safety concerns.
Question 8: Obsessive-Compulsive Disorder
A client with obsessive-compulsive disorder repeatedly washes their hands because of an
intense fear of contamination. Which intervention is most appropriate?
A. Shame the client for repeating the behavior. B. Immediately prevent every ritual without a
treatment plan. C. Assess how the rituals affect daily functioning and collaborate on evidence-
based treatment. D. Tell the client that the feared contamination is definitely present.
Correct Answer: C. Assess how the rituals affect daily functioning and collaborate on evidence-
based treatment.
Rationale: OCD involves obsessions, compulsions, or both, which can cause significant distress
and interfere with daily life. Cognitive behavioral therapy, particularly exposure and response
prevention, and appropriate medication such as an SSRI may be used. Treatment should be
collaborative and planned rather than punitive or abruptly imposed without considering safety
and distress.
Question 9: Panic Attack
A client suddenly develops intense fear, chest tightness, rapid breathing, and trembling. What
should the nurse do first?
A. Leave the client alone in a quiet room. B. Remain with the client, assess immediate physical
safety, and speak calmly using short statements. C. Ask the client to explain childhood
experiences. D. Encourage vigorous exercise to release tension.
Correct Answer: B. Remain with the client, assess immediate physical safety, and speak calmly
using short statements.
Rationale: During a panic episode, the client may struggle to process complex information. Calm
presence, brief reassurance, reduced stimulation, and simple grounding strategies can help. The
nurse must also assess symptoms and medical warning signs because chest tightness and
,A client tells the nurse, “Nobody cares about me, and my life is meaningless.” Which response
demonstrates therapeutic communication?
A. “You should not think so negatively.” B. “Other people have problems worse than yours.” C.
“Tell me more about what has been making you feel this way.” D. “You will feel better once you
leave the hospital.”
Correct Answer: C. “Tell me more about what has been making you feel this way.”
Rationale: Open-ended statements encourage clients to express their feelings and help the
nurse understand their concerns. Responses A and B minimize the client's emotions, while D
offers false reassurance without assessing the situation.
Question 3: Suicide Risk Assessment
A client admitted with major depressive disorder says, “I have decided to end my life tonight.”
What should the nurse do first?
A. Encourage the client to attend a recreational activity. B. Ask directly about the suicide plan,
access to means, and immediate intent while ensuring safety. C. Tell the client that suicide is
never the answer. D. Leave the client alone to allow time for reflection.
Correct Answer: B. Ask directly about the suicide plan, access to means, and immediate intent
while ensuring safety.
Rationale: A specific statement about suicide indicates potentially imminent danger. The nurse
should assess immediate risk, maintain observation appropriate to the level of danger, remove
accessible hazards, and promptly notify the responsible clinical team. Leaving the client alone or
relying on reassurance can increase risk. Directly asking about suicide does not create suicidal
thoughts.
Question 4: Major Depressive Disorder
Which finding is most characteristic of major depressive disorder?
A. Persistent elevated mood and decreased need for sleep. B. Recurrent hallucinations without
mood changes. C. Persistent depressed mood or loss of interest accompanied by other
depressive symptoms. D. Brief anxiety before public speaking.
Correct Answer: C. Persistent depressed mood or loss of interest accompanied by other
depressive symptoms.
Rationale: Major depressive disorder involves depressed mood or diminished interest or
pleasure, alongside additional symptoms such as sleep disturbance, appetite changes, fatigue,
impaired concentration, feelings of worthlessness, or suicidal thoughts. Symptoms generally
,persist for at least two weeks and cause clinically significant distress or impairment. Mania is
more characteristic of bipolar disorder, while brief situational anxiety alone does not establish
major depression.
Question 5: Bipolar Disorder — Acute Mania
A client experiencing acute mania is speaking rapidly, sleeping very little, and attempting to
participate in several activities simultaneously. Which nursing intervention is most appropriate?
A. Encourage participation in competitive group activities. B. Provide a low-stimulation
environment and establish clear, consistent limits. C. Challenge every unrealistic statement
made by the client. D. Encourage the client to make major financial decisions while energetic.
Correct Answer: B. Provide a low-stimulation environment and establish clear, consistent limits.
Rationale: Mania can cause impulsivity, poor judgment, excessive activity, and reduced sleep. A
quiet environment, simple directions, consistent boundaries, adequate hydration and nutrition,
and protection from risky behavior promote safety. Competitive or highly stimulating activities
may worsen agitation. Major financial and other consequential decisions should be postponed
when judgment is impaired.
Question 6: Schizophrenia — Auditory Hallucinations
A client with schizophrenia tells the nurse, “I hear voices saying I am worthless.” Which
response is best?
A. “The voices are real, and you should obey them.” B. “I do not hear the voices, but I
understand that they feel real to you. Are they telling you to hurt yourself or anyone else?” C.
“Stop imagining things.” D. “Why are you making up these stories?”
Correct Answer: B. “I do not hear the voices, but I understand that they feel real to you. Are
they telling you to hurt yourself or anyone else?”
Rationale: The nurse should acknowledge the client's experience without confirming the
hallucination as reality. Asking about harmful commands helps assess immediate safety.
Dismissing or ridiculing the client damages trust, while agreeing with the hallucination
reinforces the false perception.
Question 7: Delusions
A client believes that hospital staff have implanted a tracking device inside their body. Which
response is most therapeutic?
, A. “That is ridiculous; no one would do that.” B. “I know the staff are tracking you.” C. “I
understand that this feels frightening. I do not have evidence that a device has been implanted.”
D. “You should stop thinking about it.”
Correct Answer: C. “I understand that this feels frightening. I do not have evidence that a device
has been implanted.”
Rationale: The nurse should recognize the client's distress while presenting reality calmly.
Arguing aggressively can increase defensiveness, while agreeing with the delusion reinforces the
belief. The nurse should assess related fears, behavior, and safety concerns.
Question 8: Obsessive-Compulsive Disorder
A client with obsessive-compulsive disorder repeatedly washes their hands because of an
intense fear of contamination. Which intervention is most appropriate?
A. Shame the client for repeating the behavior. B. Immediately prevent every ritual without a
treatment plan. C. Assess how the rituals affect daily functioning and collaborate on evidence-
based treatment. D. Tell the client that the feared contamination is definitely present.
Correct Answer: C. Assess how the rituals affect daily functioning and collaborate on evidence-
based treatment.
Rationale: OCD involves obsessions, compulsions, or both, which can cause significant distress
and interfere with daily life. Cognitive behavioral therapy, particularly exposure and response
prevention, and appropriate medication such as an SSRI may be used. Treatment should be
collaborative and planned rather than punitive or abruptly imposed without considering safety
and distress.
Question 9: Panic Attack
A client suddenly develops intense fear, chest tightness, rapid breathing, and trembling. What
should the nurse do first?
A. Leave the client alone in a quiet room. B. Remain with the client, assess immediate physical
safety, and speak calmly using short statements. C. Ask the client to explain childhood
experiences. D. Encourage vigorous exercise to release tension.
Correct Answer: B. Remain with the client, assess immediate physical safety, and speak calmly
using short statements.
Rationale: During a panic episode, the client may struggle to process complex information. Calm
presence, brief reassurance, reduced stimulation, and simple grounding strategies can help. The
nurse must also assess symptoms and medical warning signs because chest tightness and
