1. A client diagnosed with depression is prescribed fluoxetine. The
nurse knows that a potential side effect of this medication is:
A) Dry mouth
B) Weight gain
C) Increased energy
D) Sedation
Answer: C) Increased energy
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI).
One of the early side effects is increased energy or agitation, which may
occur before the full therapeutic effect of the medication (which
generally takes 2–4 weeks). Weight gain, sedation, and dry mouth are
not common early effects of fluoxetine.
2. A client is admitted to the psychiatric unit with a diagnosis of
bipolar disorder. The nurse should be most concerned if the client
reports:
A) "I feel great and am making plans for the future."
B) "I feel depressed and have trouble getting out of bed."
C) "I think I have too much energy and cannot sit still."
D) "I haven't been eating or sleeping well."
Answer: A) "I feel great and am making plans for the future."
Rationale: During manic episodes, clients with bipolar disorder can
experience an inflated sense of self-esteem or grandiosity, as well as
excessive energy and unrealistic plans for the future. This can lead to
impulsivity or risk-taking behavior. The statement reflects signs of
mania, which could lead to a lack of judgment and self-destructive
behaviors. Options B, C, and D are less indicative of a manic episode.
,3. A nurse is conducting a mental status examination with a client. The
nurse notices that the client is unable to recall three objects after 5
minutes. The nurse should:
A) Document this as an indication of memory impairment.
B) Ask the client to recall the three objects again.
C) Ask the client to recall personal information, like their birthdate.
D) Reassess the client in 10 minutes.
Answer: C) Ask the client to recall personal information, like their
birthdate.
Rationale: The nurse should assess whether memory impairment is a
more general or specific issue. Asking about personal information (e.g.,
birthdate) helps determine if the memory issue is related to short-term
memory, or if there might be more global cognitive impairment.
Reassessing in 10 minutes or only documenting memory impairment
would not address the underlying cause immediately.
4. A nurse is assessing a client with schizophrenia. The client reports
hearing voices telling him to hurt others. Which action should the
nurse take first?
A) Ask the client to describe the voices.
B) Implement precautions for safety.
C) Offer reassurance that the voices are not real.
D) Encourage the client to express feelings about the voices.
Answer: B) Implement precautions for safety.
Rationale: Safety is always the priority when a client is at risk of
harming themselves or others. Since the client is reporting auditory
,hallucinations telling him to hurt others, the nurse should first ensure
that the environment is safe and that precautions are taken. Afterward,
the nurse can explore the hallucinations (A), but safety comes first.
5. A client diagnosed with post-traumatic stress disorder (PTSD) is
experiencing flashbacks. Which of the following is the most
therapeutic action for the nurse to take?
A) "You need to stop thinking about the trauma and focus on something
else."
B) "Tell me about the flashback you're experiencing."
C) "I will help you distract yourself by engaging in a different activity."
D) "Let's talk about your past trauma in more detail."
Answer: C) "I will help you distract yourself by engaging in a different
activity."
Rationale: Flashbacks are a distressing symptom of PTSD, where the
client feels as though they are reliving the traumatic event. Helping the
client engage in a different activity can be a grounding technique that
provides distraction and reduces the intensity of the flashback. Asking
the client to talk about it or focusing on the trauma can often intensify
the flashback.
6. A nurse is educating a client about their prescription for lithium.
Which of the following statements by the client indicates a need for
further teaching?
A) "I will drink plenty of fluids, especially water."
B) "I will avoid taking over-the-counter medications like ibuprofen."
, C) "I will have regular blood tests to check my lithium levels."
D) "I should try to limit my salt intake to decrease side effects."
Answer: D) "I should try to limit my salt intake to decrease side
effects."
Rationale: Clients taking lithium should maintain a consistent level of
sodium in their diet. A low-sodium diet can increase lithium levels,
potentially leading to toxicity. It's important to avoid sudden changes in
salt intake, not limit it. The other statements are correct: adequate
hydration, avoiding NSAIDs like ibuprofen (which can affect kidney
function and increase lithium levels), and regular blood tests are
important for monitoring therapy.
7. A nurse is caring for a client who has a history of alcohol abuse and
is in withdrawal. Which symptom would the nurse expect to see
within the first 24 hours of alcohol withdrawal?
A) Seizures
B) Delirium tremens
C) Tachycardia and hypertension
D) Hypoglycemia
Answer: C) Tachycardia and hypertension
Rationale: Within the first 24 hours of alcohol withdrawal, common
symptoms include autonomic hyperactivity such as tachycardia,
hypertension, tremors, and anxiety. Delirium tremens (D) and seizures
are typically seen 48-72 hours after the last drink. Hypoglycemia (D) is
not a direct result of alcohol withdrawal.
nurse knows that a potential side effect of this medication is:
A) Dry mouth
B) Weight gain
C) Increased energy
D) Sedation
Answer: C) Increased energy
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI).
One of the early side effects is increased energy or agitation, which may
occur before the full therapeutic effect of the medication (which
generally takes 2–4 weeks). Weight gain, sedation, and dry mouth are
not common early effects of fluoxetine.
2. A client is admitted to the psychiatric unit with a diagnosis of
bipolar disorder. The nurse should be most concerned if the client
reports:
A) "I feel great and am making plans for the future."
B) "I feel depressed and have trouble getting out of bed."
C) "I think I have too much energy and cannot sit still."
D) "I haven't been eating or sleeping well."
Answer: A) "I feel great and am making plans for the future."
Rationale: During manic episodes, clients with bipolar disorder can
experience an inflated sense of self-esteem or grandiosity, as well as
excessive energy and unrealistic plans for the future. This can lead to
impulsivity or risk-taking behavior. The statement reflects signs of
mania, which could lead to a lack of judgment and self-destructive
behaviors. Options B, C, and D are less indicative of a manic episode.
,3. A nurse is conducting a mental status examination with a client. The
nurse notices that the client is unable to recall three objects after 5
minutes. The nurse should:
A) Document this as an indication of memory impairment.
B) Ask the client to recall the three objects again.
C) Ask the client to recall personal information, like their birthdate.
D) Reassess the client in 10 minutes.
Answer: C) Ask the client to recall personal information, like their
birthdate.
Rationale: The nurse should assess whether memory impairment is a
more general or specific issue. Asking about personal information (e.g.,
birthdate) helps determine if the memory issue is related to short-term
memory, or if there might be more global cognitive impairment.
Reassessing in 10 minutes or only documenting memory impairment
would not address the underlying cause immediately.
4. A nurse is assessing a client with schizophrenia. The client reports
hearing voices telling him to hurt others. Which action should the
nurse take first?
A) Ask the client to describe the voices.
B) Implement precautions for safety.
C) Offer reassurance that the voices are not real.
D) Encourage the client to express feelings about the voices.
Answer: B) Implement precautions for safety.
Rationale: Safety is always the priority when a client is at risk of
harming themselves or others. Since the client is reporting auditory
,hallucinations telling him to hurt others, the nurse should first ensure
that the environment is safe and that precautions are taken. Afterward,
the nurse can explore the hallucinations (A), but safety comes first.
5. A client diagnosed with post-traumatic stress disorder (PTSD) is
experiencing flashbacks. Which of the following is the most
therapeutic action for the nurse to take?
A) "You need to stop thinking about the trauma and focus on something
else."
B) "Tell me about the flashback you're experiencing."
C) "I will help you distract yourself by engaging in a different activity."
D) "Let's talk about your past trauma in more detail."
Answer: C) "I will help you distract yourself by engaging in a different
activity."
Rationale: Flashbacks are a distressing symptom of PTSD, where the
client feels as though they are reliving the traumatic event. Helping the
client engage in a different activity can be a grounding technique that
provides distraction and reduces the intensity of the flashback. Asking
the client to talk about it or focusing on the trauma can often intensify
the flashback.
6. A nurse is educating a client about their prescription for lithium.
Which of the following statements by the client indicates a need for
further teaching?
A) "I will drink plenty of fluids, especially water."
B) "I will avoid taking over-the-counter medications like ibuprofen."
, C) "I will have regular blood tests to check my lithium levels."
D) "I should try to limit my salt intake to decrease side effects."
Answer: D) "I should try to limit my salt intake to decrease side
effects."
Rationale: Clients taking lithium should maintain a consistent level of
sodium in their diet. A low-sodium diet can increase lithium levels,
potentially leading to toxicity. It's important to avoid sudden changes in
salt intake, not limit it. The other statements are correct: adequate
hydration, avoiding NSAIDs like ibuprofen (which can affect kidney
function and increase lithium levels), and regular blood tests are
important for monitoring therapy.
7. A nurse is caring for a client who has a history of alcohol abuse and
is in withdrawal. Which symptom would the nurse expect to see
within the first 24 hours of alcohol withdrawal?
A) Seizures
B) Delirium tremens
C) Tachycardia and hypertension
D) Hypoglycemia
Answer: C) Tachycardia and hypertension
Rationale: Within the first 24 hours of alcohol withdrawal, common
symptoms include autonomic hyperactivity such as tachycardia,
hypertension, tremors, and anxiety. Delirium tremens (D) and seizures
are typically seen 48-72 hours after the last drink. Hypoglycemia (D) is
not a direct result of alcohol withdrawal.
