1. A nurse is assessing a client diagnosed with major depressive
disorder. Which of the following findings would the nurse expect to
observe?
A. Elevated mood
B. Increased energy
C. Feelings of hopelessness
D. Grandiosity
Answer: C. Feelings of hopelessness
Rationale: Major depressive disorder is characterized by persistent
sadness, hopelessness, and a lack of interest or pleasure in daily
activities. Elevated mood, increased energy, and grandiosity are more
commonly associated with conditions like bipolar disorder or mania.
2. Which of the following is a priority nursing intervention for a
patient with schizophrenia who is exhibiting delusions?
A. Reinforce the patient's delusions to reduce anxiety
B. Offer reality-based explanations to counter the delusions
C. Focus on the patient's physical appearance
D. Encourage the patient to talk about their feelings
Answer: B. Offer reality-based explanations to counter the delusions
Rationale: It is important to gently challenge the delusion by offering a
reality-based explanation. Reinforcing delusions can worsen the
patient's confusion. The focus should remain on safety and stabilization.
3. A nurse is caring for a client with generalized anxiety disorder
(GAD). Which of the following is a characteristic symptom of this
disorder?
,A. Sudden intense fear or discomfort
B. Excessive worry about everyday events
C. Intrusive, repetitive thoughts
D. Avoidance of social situations
Answer: B. Excessive worry about everyday events
Rationale: Generalized anxiety disorder is marked by chronic, excessive
worry and anxiety about a variety of events or activities. Symptoms of
other conditions, like panic disorder or obsessive-compulsive disorder,
are different from the persistent worry seen in GAD.
4. Which of the following is a common side effect of selective
serotonin reuptake inhibitors (SSRIs)?
A. Weight loss
B. Increased energy
C. Sexual dysfunction
D. Increased appetite
Answer: C. Sexual dysfunction
Rationale: SSRIs, such as fluoxetine or sertraline, are commonly
prescribed for depression and anxiety but are known to cause sexual
side effects, including decreased libido and delayed orgasm. Weight loss
or appetite changes are not typical effects.
5. A client diagnosed with borderline personality disorder (BPD) is
exhibiting impulsive behavior. Which of the following interventions is
most appropriate?
A. Set firm and clear boundaries
B. Encourage emotional expression without limits
, C. Avoid discussing the client's behavior to reduce conflict
D. Validate the client's feelings, but avoid consequences
Answer: A. Set firm and clear boundaries
Rationale: Clients with BPD often struggle with impulsivity and
emotional instability. Setting clear and consistent boundaries helps
provide structure and reduces the likelihood of impulsive actions.
Validating feelings is important, but maintaining boundaries is essential
for safety.
6. A nurse is providing education to a client who is starting lithium
therapy for bipolar disorder. Which of the following statements by the
client indicates a need for further teaching?
A. "I should maintain a consistent intake of salt and fluids."
B. "I need to get regular blood tests to monitor my lithium levels."
C. "I can stop the medication once I start feeling better."
D. "I should avoid drinking alcohol while taking lithium."
Answer: C. "I can stop the medication once I start feeling better."
Rationale: Lithium is a mood stabilizer that must be taken consistently
to maintain therapeutic levels and prevent relapse of manic or
depressive episodes. The client should be educated that discontinuing
the medication abruptly can cause a relapse or withdrawal symptoms.
7. A nurse is assessing a patient with post-traumatic stress disorder
(PTSD). Which of the following is a common symptom of PTSD?
A. Flashbacks
B. Sudden, severe mood swings
disorder. Which of the following findings would the nurse expect to
observe?
A. Elevated mood
B. Increased energy
C. Feelings of hopelessness
D. Grandiosity
Answer: C. Feelings of hopelessness
Rationale: Major depressive disorder is characterized by persistent
sadness, hopelessness, and a lack of interest or pleasure in daily
activities. Elevated mood, increased energy, and grandiosity are more
commonly associated with conditions like bipolar disorder or mania.
2. Which of the following is a priority nursing intervention for a
patient with schizophrenia who is exhibiting delusions?
A. Reinforce the patient's delusions to reduce anxiety
B. Offer reality-based explanations to counter the delusions
C. Focus on the patient's physical appearance
D. Encourage the patient to talk about their feelings
Answer: B. Offer reality-based explanations to counter the delusions
Rationale: It is important to gently challenge the delusion by offering a
reality-based explanation. Reinforcing delusions can worsen the
patient's confusion. The focus should remain on safety and stabilization.
3. A nurse is caring for a client with generalized anxiety disorder
(GAD). Which of the following is a characteristic symptom of this
disorder?
,A. Sudden intense fear or discomfort
B. Excessive worry about everyday events
C. Intrusive, repetitive thoughts
D. Avoidance of social situations
Answer: B. Excessive worry about everyday events
Rationale: Generalized anxiety disorder is marked by chronic, excessive
worry and anxiety about a variety of events or activities. Symptoms of
other conditions, like panic disorder or obsessive-compulsive disorder,
are different from the persistent worry seen in GAD.
4. Which of the following is a common side effect of selective
serotonin reuptake inhibitors (SSRIs)?
A. Weight loss
B. Increased energy
C. Sexual dysfunction
D. Increased appetite
Answer: C. Sexual dysfunction
Rationale: SSRIs, such as fluoxetine or sertraline, are commonly
prescribed for depression and anxiety but are known to cause sexual
side effects, including decreased libido and delayed orgasm. Weight loss
or appetite changes are not typical effects.
5. A client diagnosed with borderline personality disorder (BPD) is
exhibiting impulsive behavior. Which of the following interventions is
most appropriate?
A. Set firm and clear boundaries
B. Encourage emotional expression without limits
, C. Avoid discussing the client's behavior to reduce conflict
D. Validate the client's feelings, but avoid consequences
Answer: A. Set firm and clear boundaries
Rationale: Clients with BPD often struggle with impulsivity and
emotional instability. Setting clear and consistent boundaries helps
provide structure and reduces the likelihood of impulsive actions.
Validating feelings is important, but maintaining boundaries is essential
for safety.
6. A nurse is providing education to a client who is starting lithium
therapy for bipolar disorder. Which of the following statements by the
client indicates a need for further teaching?
A. "I should maintain a consistent intake of salt and fluids."
B. "I need to get regular blood tests to monitor my lithium levels."
C. "I can stop the medication once I start feeling better."
D. "I should avoid drinking alcohol while taking lithium."
Answer: C. "I can stop the medication once I start feeling better."
Rationale: Lithium is a mood stabilizer that must be taken consistently
to maintain therapeutic levels and prevent relapse of manic or
depressive episodes. The client should be educated that discontinuing
the medication abruptly can cause a relapse or withdrawal symptoms.
7. A nurse is assessing a patient with post-traumatic stress disorder
(PTSD). Which of the following is a common symptom of PTSD?
A. Flashbacks
B. Sudden, severe mood swings
