1. A nurse is assessing a client diagnosed with major depressive
disorder. The client reports feelings of hopelessness and helplessness,
as well as thoughts of self-harm. Which action should the nurse
prioritize?
A) Administering an antidepressant
B) Encouraging the client to express feelings
C) Implementing suicide precautions
D) Providing education on healthy coping strategies
Answer: C) Implementing suicide precautions
Rationale: A priority for a client with major depressive disorder and
suicidal thoughts is safety. Implementing suicide precautions helps
prevent self-harm. While other interventions are also important,
ensuring the client's safety is paramount. Administering medication and
encouraging expression of feelings can follow once safety is ensured.
2. A nurse is caring for a client with schizophrenia who exhibits
paranoid delusions. The client states, "The doctors are trying to poison
me." Which response by the nurse is most therapeutic?
A) "You are mistaken. The doctors are trying to help you."
B) "I understand that you believe the doctors are trying to poison you,
but I assure you they are not."
C) "Don't worry, you’re just imagining things."
D) "Tell me why you think the doctors are trying to poison you."
Answer: B) "I understand that you believe the doctors are trying to
poison you, but I assure you they are not."
Rationale: A therapeutic response acknowledges the client's feelings
while gently offering reassurance. It is important to recognize and
,validate the client's delusions without reinforcing them. This response
maintains a respectful and empathetic approach while minimizing
confrontation.
3. Which of the following is a common side effect of lithium therapy
for bipolar disorder?
A) Weight loss
B) Insomnia
C) Tremors
D) Hypertension
Answer: C) Tremors
Rationale: Tremors are a common side effect of lithium therapy,
especially at higher levels. Other side effects of lithium include
gastrointestinal upset, polyuria, and weight gain, but tremors are most
frequently observed. Close monitoring of lithium levels is required to
avoid toxicity.
4. A nurse is caring for a client diagnosed with generalized anxiety
disorder (GAD). Which symptom is most characteristic of GAD?
A) Fear of social situations
B) Sudden, intense feelings of dread or panic
C) Chronic, excessive worry about various aspects of life
D) Flashbacks to a traumatic event
Answer: C) Chronic, excessive worry about various aspects of life
Rationale: Generalized anxiety disorder is characterized by chronic,
excessive worry about a variety of topics such as work, health, and
social situations. This worry is difficult to control and is often
,accompanied by physical symptoms such as restlessness, fatigue, and
muscle tension.
5. A nurse is teaching a client about cognitive-behavioral therapy (CBT)
for depression. Which statement by the client indicates an
understanding of CBT?
A) "CBT will help me forget all of my past traumatic events."
B) "CBT will teach me to change my negative thought patterns."
C) "CBT focuses on taking medication to reduce my symptoms."
D) "CBT is mostly about talking about my feelings."
Answer: B) "CBT will teach me to change my negative thought
patterns."
Rationale: Cognitive-behavioral therapy (CBT) focuses on identifying
and changing negative thought patterns and behaviors that contribute
to depression. It is a structured, goal-oriented therapy that teaches
clients how to challenge and modify unhelpful thoughts and behaviors.
CBT does not aim to erase memories or focus solely on medication.
6. A nurse is assessing a client with a history of alcohol use disorder.
Which statement by the client suggests a risk for relapse?
A) "I have been attending AA meetings regularly."
B) "I feel like I am finally in control of my drinking."
C) "I have not had a drink in six months."
D) "I sometimes feel stressed, but I am managing it without alcohol."
Answer: B) "I feel like I am finally in control of my drinking."
Rationale: The statement "I feel like I am finally in control of my
drinking" suggests that the client may be overestimating their ability to
, maintain sobriety and could be at risk for relapse. Individuals with
alcohol use disorder often need ongoing support, and feelings of "being
in control" may lead to complacency. Continuous self-monitoring and
participation in support groups are crucial for long-term recovery.
7. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following interventions is most appropriate for
helping the client manage flashbacks?
A) Encouraging the client to confront the traumatic event in detail
B) Keeping the environment calm and safe, minimizing stimuli
C) Providing an outlet for the client to express anger towards others
D) Encouraging the client to avoid any reminders of the trauma
Answer: B) Keeping the environment calm and safe, minimizing stimuli
Rationale: Clients with PTSD may experience flashbacks in response to
triggers. It is important to keep the environment calm and safe and to
reduce stimuli that could increase anxiety. Creating a sense of security
helps the client feel more grounded and less likely to be overwhelmed
during a flashback. Avoiding confrontation or denial of the trauma is not
appropriate.
8. A nurse is teaching a client diagnosed with obsessive-compulsive
disorder (OCD) about the nature of the disorder. Which statement by
the client indicates a correct understanding of OCD?
A) "My compulsions are just bad habits that I can stop anytime I want."
B) "I can’t control my thoughts, but I can control my behaviors."
C) "I do the compulsive behaviors because they help me feel less
disorder. The client reports feelings of hopelessness and helplessness,
as well as thoughts of self-harm. Which action should the nurse
prioritize?
A) Administering an antidepressant
B) Encouraging the client to express feelings
C) Implementing suicide precautions
D) Providing education on healthy coping strategies
Answer: C) Implementing suicide precautions
Rationale: A priority for a client with major depressive disorder and
suicidal thoughts is safety. Implementing suicide precautions helps
prevent self-harm. While other interventions are also important,
ensuring the client's safety is paramount. Administering medication and
encouraging expression of feelings can follow once safety is ensured.
2. A nurse is caring for a client with schizophrenia who exhibits
paranoid delusions. The client states, "The doctors are trying to poison
me." Which response by the nurse is most therapeutic?
A) "You are mistaken. The doctors are trying to help you."
B) "I understand that you believe the doctors are trying to poison you,
but I assure you they are not."
C) "Don't worry, you’re just imagining things."
D) "Tell me why you think the doctors are trying to poison you."
Answer: B) "I understand that you believe the doctors are trying to
poison you, but I assure you they are not."
Rationale: A therapeutic response acknowledges the client's feelings
while gently offering reassurance. It is important to recognize and
,validate the client's delusions without reinforcing them. This response
maintains a respectful and empathetic approach while minimizing
confrontation.
3. Which of the following is a common side effect of lithium therapy
for bipolar disorder?
A) Weight loss
B) Insomnia
C) Tremors
D) Hypertension
Answer: C) Tremors
Rationale: Tremors are a common side effect of lithium therapy,
especially at higher levels. Other side effects of lithium include
gastrointestinal upset, polyuria, and weight gain, but tremors are most
frequently observed. Close monitoring of lithium levels is required to
avoid toxicity.
4. A nurse is caring for a client diagnosed with generalized anxiety
disorder (GAD). Which symptom is most characteristic of GAD?
A) Fear of social situations
B) Sudden, intense feelings of dread or panic
C) Chronic, excessive worry about various aspects of life
D) Flashbacks to a traumatic event
Answer: C) Chronic, excessive worry about various aspects of life
Rationale: Generalized anxiety disorder is characterized by chronic,
excessive worry about a variety of topics such as work, health, and
social situations. This worry is difficult to control and is often
,accompanied by physical symptoms such as restlessness, fatigue, and
muscle tension.
5. A nurse is teaching a client about cognitive-behavioral therapy (CBT)
for depression. Which statement by the client indicates an
understanding of CBT?
A) "CBT will help me forget all of my past traumatic events."
B) "CBT will teach me to change my negative thought patterns."
C) "CBT focuses on taking medication to reduce my symptoms."
D) "CBT is mostly about talking about my feelings."
Answer: B) "CBT will teach me to change my negative thought
patterns."
Rationale: Cognitive-behavioral therapy (CBT) focuses on identifying
and changing negative thought patterns and behaviors that contribute
to depression. It is a structured, goal-oriented therapy that teaches
clients how to challenge and modify unhelpful thoughts and behaviors.
CBT does not aim to erase memories or focus solely on medication.
6. A nurse is assessing a client with a history of alcohol use disorder.
Which statement by the client suggests a risk for relapse?
A) "I have been attending AA meetings regularly."
B) "I feel like I am finally in control of my drinking."
C) "I have not had a drink in six months."
D) "I sometimes feel stressed, but I am managing it without alcohol."
Answer: B) "I feel like I am finally in control of my drinking."
Rationale: The statement "I feel like I am finally in control of my
drinking" suggests that the client may be overestimating their ability to
, maintain sobriety and could be at risk for relapse. Individuals with
alcohol use disorder often need ongoing support, and feelings of "being
in control" may lead to complacency. Continuous self-monitoring and
participation in support groups are crucial for long-term recovery.
7. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following interventions is most appropriate for
helping the client manage flashbacks?
A) Encouraging the client to confront the traumatic event in detail
B) Keeping the environment calm and safe, minimizing stimuli
C) Providing an outlet for the client to express anger towards others
D) Encouraging the client to avoid any reminders of the trauma
Answer: B) Keeping the environment calm and safe, minimizing stimuli
Rationale: Clients with PTSD may experience flashbacks in response to
triggers. It is important to keep the environment calm and safe and to
reduce stimuli that could increase anxiety. Creating a sense of security
helps the client feel more grounded and less likely to be overwhelmed
during a flashback. Avoiding confrontation or denial of the trauma is not
appropriate.
8. A nurse is teaching a client diagnosed with obsessive-compulsive
disorder (OCD) about the nature of the disorder. Which statement by
the client indicates a correct understanding of OCD?
A) "My compulsions are just bad habits that I can stop anytime I want."
B) "I can’t control my thoughts, but I can control my behaviors."
C) "I do the compulsive behaviors because they help me feel less
