ACTUAL-Style Practice Questions & Answers, RN Nursing Exam Prep,
Psychiatric Nursing, Community Health Assessment, Therapeutic
Communication, Mental Health Disorders, Population Health, and Detailed
Rationales
Question 1: A nurse is assessing a client who has generalized anxiety
disorder (GAD). Which of the following findings should the nurse
expect?
A. Episodic panic attacks lasting 10 to 15 minutes
B. Excessive worry occurring more days than not for at least 6 months
C. Fear of specific objects or situations
D. Recurrent intrusive thoughts that the client attempts to suppress
CORRECT ANSWER: B. Excessive worry occurring more days than not
for at least 6 months
Rationale: Generalized anxiety disorder is characterized by persistent,
excessive, and difficult-to-control worry about multiple areas of life
occurring more days than not for at least 6 months. Episodic panic attacks
(A) suggest panic disorder, fear of specific objects (C) suggests a specific
phobia, and recurrent intrusive thoughts (D) suggest obsessive-compulsive
disorder.
Question 2: A nurse is caring for a client experiencing a panic attack.
Which of the following actions should the nurse take first?
A. Teach the client deep breathing exercises
B. Administer a prescribed benzodiazepine
C. Stay with the client and remain calm
D. Escort the client to a quiet, low-stimulus environment
CORRECT ANSWER: C. Stay with the client and remain calm
Rationale: During an acute panic attack, the nurse's priority is to stay with
the client and maintain a calm presence to promote safety and reduce
anxiety. Teaching deep breathing (A) and moving the client to a quiet
environment (D) are appropriate but secondary, and medication (B) is not
the first-line nursing action.
Question 3: A client is prescribed sertraline for major depressive
disorder. Which of the following statements by the client indicates a
need for further teaching?
,A. "I should take this medication in the morning with food."
B. "I may notice an improvement in my mood within a few days."
C. "I should avoid drinking alcohol while taking this medication."
D. "I should report any thoughts of self-harm to my provider immediately."
CORRECT ANSWER: B. "I may notice an improvement in my mood
within a few days."
Rationale: SSRIs such as sertraline typically take 2 to 4 weeks to produce
noticeable therapeutic effects on mood. Expecting improvement within a
few days indicates a misunderstanding. Taking the medication in the
morning (A) helps prevent insomnia, avoiding alcohol (C) is recommended,
and reporting self-harm thoughts (D) is essential.
Question 4: A nurse is assessing a client who has been diagnosed with
bipolar I disorder. Which of the following findings indicates the client is
experiencing a manic episode?
A. Decreased need for sleep and grandiosity
B. Flat affect and social withdrawal
C. Intrusive thoughts and compulsive rituals
D. Hallucinations and disorganized speech
CORRECT ANSWER: A. Decreased need for sleep and grandiosity
Rationale: Manic episodes are characterized by decreased need for sleep,
grandiosity, increased goal-directed activity, and pressured speech. Flat
affect and withdrawal (B) suggest depression, intrusive thoughts (C)
suggest OCD, and hallucinations with disorganized speech (D) suggest
schizophrenia.
Question 5: A client with schizophrenia is prescribed haloperidol.
Which of the following findings should the nurse report immediately as
a possible sign of neuroleptic malignant syndrome (NMS)?
A. Dry mouth and constipation
B. Temperature of 102.4°F (39.1°C) and muscle rigidity
C. Weight gain and increased appetite
D. Photosensitivity and skin rash
CORRECT ANSWER: B. Temperature of 102.4°F (39.1°C) and muscle
rigidity
,Rationale: NMS is a life-threatening complication of antipsychotic therapy
characterized by hyperthermia, severe muscle rigidity, altered mental
status, and autonomic instability. Dry mouth (A), weight gain (C), and
photosensitivity (D) are common but non-life-threatening adverse effects.
Question 6: A nurse is conducting a community health assessment.
Which of the following best describes the purpose of a windshield
survey?
A. To collect epidemiological data on chronic diseases
B. To observe the community's physical environment and resources
C. To evaluate the effectiveness of health education programs
D. To determine individual clients' health literacy levels
CORRECT ANSWER: B. To observe the community's physical
environment and resources
Rationale: A windshield survey is a systematic observation of a community
from a moving vehicle or on foot, used to assess the physical environment,
housing, resources, and potential health hazards. It is not an
epidemiological study (A), a program evaluation (C), or an individual
assessment (D).
Question 7: A nurse is teaching a client about lithium therapy. Which of
the following instructions should the nurse include?
A. "Increase your sodium intake while taking this medication."
B. "Maintain a consistent fluid and sodium intake."
C. "Take this medication on an empty stomach."
D. "Expect therapeutic effects within 24 hours."
CORRECT ANSWER: B. "Maintain a consistent fluid and sodium intake."
Rationale: Lithium levels are influenced by sodium and fluid balance;
inconsistent intake can lead to toxicity or reduced efficacy. Clients should
maintain consistent sodium and fluid intake. Increasing sodium (A) is not
advised, taking on an empty stomach (C) may worsen GI upset, and
therapeutic effects (D) take 1 to 3 weeks.
Question 8: A nurse is caring for a client who is experiencing alcohol
withdrawal. Which of the following medications should the nurse
anticipate administering?
, A. Naltrexone
B. Lorazepam
C. Disulfiram
D. Acamprosate
CORRECT ANSWER: B. Lorazepam
Rationale: Benzodiazepines such as lorazepam are the first-line treatment
for alcohol withdrawal to prevent seizures and delirium tremens.
Naltrexone (A) and acamprosate (D) reduce cravings, and disulfiram (C) is
used for aversion therapy after detoxification.
Question 9: A client with anorexia nervosa is admitted to an inpatient
unit. Which of the following is the priority nursing intervention?
A. Monitor the client's weight daily
B. Establish a therapeutic relationship
C. Restore the client's nutritional status
D. Encourage the client to express feelings
CORRECT ANSWER: C. Restore the client's nutritional status
Rationale: The priority for a client with anorexia nervosa is restoring
nutritional status and stabilizing physical health, as malnutrition can be
life-threatening. Monitoring weight (A), building rapport (B), and
encouraging expression of feelings (D) are important but secondary to
physiological stabilization.
Question 10: A nurse is assessing a client who has post-traumatic
stress disorder (PTSD). Which of the following findings should the nurse
expect?
A. Intrusive memories and hypervigilance
B. Grandiosity and decreased need for sleep
C. Compulsive rituals and fear of contamination
D. Anhedonia and psychomotor retardation
CORRECT ANSWER: A. Intrusive memories and hypervigilance
Rationale: PTSD is characterized by intrusive memories, flashbacks,
hypervigilance, avoidance, and negative mood alterations. Grandiosity (B)
suggests mania, compulsive rituals (C) suggest OCD, and anhedonia with
psychomotor retardation (D) suggests depression.