1. A nurse is working with a patient diagnosed with major depressive
disorder. The nurse notes that the patient is withdrawn, has trouble
concentrating, and reports feeling hopeless. Which of the following is
the most appropriate nursing intervention?
A. Encourage the patient to talk about their feelings.
B. Provide the patient with a journal to write in.
C. Offer the patient a safe, quiet environment.
D. Suggest the patient join a support group.
Answer: C. Offer the patient a safe, quiet environment.
Rationale: A patient with major depressive disorder may experience
overwhelming feelings of hopelessness and fatigue. A quiet, safe
environment reduces stress and helps the patient to focus on recovery.
Other interventions (such as journaling or encouraging group activities)
may not be appropriate if the patient is too withdrawn to engage in
them.
2. A nurse is assessing a patient with schizophrenia. The patient says,
"I hear voices telling me to harm myself." What should the nurse's
priority action be?
A. Ask the patient to describe the voices in more detail.
B. Offer the patient a quiet space to relax.
C. Call the healthcare provider for medication adjustment.
D. Assess the patient for suicidal thoughts and intent.
Answer: D. Assess the patient for suicidal thoughts and intent.
Rationale: The priority is to assess the patient's safety. The patient
reporting hearing voices telling them to harm themselves indicates a
,potential risk for self-harm, and the nurse should assess the level of risk
to ensure the patient is safe.
3. A client with bipolar disorder is experiencing a manic episode. The
nurse should focus on which of the following nursing interventions?
A. Allow the client to express anger freely.
B. Provide a structured and calm environment.
C. Encourage the client to engage in group therapy.
D. Limit physical activity to prevent exhaustion.
Answer: B. Provide a structured and calm environment.
Rationale: During a manic episode, clients may experience heightened
energy levels, impulsivity, and agitation. A calm, structured
environment helps to reduce overstimulation and provides boundaries.
Encouraging group therapy may be overwhelming during this time.
4. A nurse is caring for a client with obsessive-compulsive disorder
(OCD). Which of the following is the most effective way to assist the
client in managing their compulsions?
A. Allow the client to engage in their rituals for as long as needed.
B. Redirect the client’s focus when they begin a ritual.
C. Set a strict schedule to limit ritual behavior.
D. Encourage the client to stop their rituals immediately.
Answer: B. Redirect the client’s focus when they begin a ritual.
Rationale: Redirecting the client’s focus helps to reduce the compulsive
behaviors in a gradual and nonjudgmental way. Encouraging an
immediate stop or strict scheduling may cause anxiety, and allowing
rituals to continue can reinforce the behavior.
, 5. A nurse is conducting a mental health assessment on a client who is
anxious. The client reports constant worry about personal safety.
Which of the following statements by the nurse would be most helpful
in building rapport?
A. "You need to stop worrying about your safety, things are fine."
B. "Can you tell me more about your concerns related to safety?"
C. "Many people feel this way, it will pass with time."
D. "Let’s focus on something more positive right now."
Answer: B. "Can you tell me more about your concerns related to
safety?"
Rationale: Asking the client to explain their concerns allows the nurse
to gain a deeper understanding of the anxiety and shows that the nurse
is attentive and nonjudgmental. The other options dismiss the client’s
feelings, which can hinder rapport building.
6. A patient with a history of alcohol dependence is undergoing
detoxification. The nurse understands that which of the following is
the most common complication during alcohol withdrawal?
A. Severe hypoglycemia
B. Seizures
C. Pulmonary embolism
D. Hemorrhagic stroke
Answer: B. Seizures
Rationale: Seizures are a common complication of alcohol withdrawal,
occurring within the first 12 to 24 hours after the last drink. They are
potentially life-threatening and require close monitoring during
disorder. The nurse notes that the patient is withdrawn, has trouble
concentrating, and reports feeling hopeless. Which of the following is
the most appropriate nursing intervention?
A. Encourage the patient to talk about their feelings.
B. Provide the patient with a journal to write in.
C. Offer the patient a safe, quiet environment.
D. Suggest the patient join a support group.
Answer: C. Offer the patient a safe, quiet environment.
Rationale: A patient with major depressive disorder may experience
overwhelming feelings of hopelessness and fatigue. A quiet, safe
environment reduces stress and helps the patient to focus on recovery.
Other interventions (such as journaling or encouraging group activities)
may not be appropriate if the patient is too withdrawn to engage in
them.
2. A nurse is assessing a patient with schizophrenia. The patient says,
"I hear voices telling me to harm myself." What should the nurse's
priority action be?
A. Ask the patient to describe the voices in more detail.
B. Offer the patient a quiet space to relax.
C. Call the healthcare provider for medication adjustment.
D. Assess the patient for suicidal thoughts and intent.
Answer: D. Assess the patient for suicidal thoughts and intent.
Rationale: The priority is to assess the patient's safety. The patient
reporting hearing voices telling them to harm themselves indicates a
,potential risk for self-harm, and the nurse should assess the level of risk
to ensure the patient is safe.
3. A client with bipolar disorder is experiencing a manic episode. The
nurse should focus on which of the following nursing interventions?
A. Allow the client to express anger freely.
B. Provide a structured and calm environment.
C. Encourage the client to engage in group therapy.
D. Limit physical activity to prevent exhaustion.
Answer: B. Provide a structured and calm environment.
Rationale: During a manic episode, clients may experience heightened
energy levels, impulsivity, and agitation. A calm, structured
environment helps to reduce overstimulation and provides boundaries.
Encouraging group therapy may be overwhelming during this time.
4. A nurse is caring for a client with obsessive-compulsive disorder
(OCD). Which of the following is the most effective way to assist the
client in managing their compulsions?
A. Allow the client to engage in their rituals for as long as needed.
B. Redirect the client’s focus when they begin a ritual.
C. Set a strict schedule to limit ritual behavior.
D. Encourage the client to stop their rituals immediately.
Answer: B. Redirect the client’s focus when they begin a ritual.
Rationale: Redirecting the client’s focus helps to reduce the compulsive
behaviors in a gradual and nonjudgmental way. Encouraging an
immediate stop or strict scheduling may cause anxiety, and allowing
rituals to continue can reinforce the behavior.
, 5. A nurse is conducting a mental health assessment on a client who is
anxious. The client reports constant worry about personal safety.
Which of the following statements by the nurse would be most helpful
in building rapport?
A. "You need to stop worrying about your safety, things are fine."
B. "Can you tell me more about your concerns related to safety?"
C. "Many people feel this way, it will pass with time."
D. "Let’s focus on something more positive right now."
Answer: B. "Can you tell me more about your concerns related to
safety?"
Rationale: Asking the client to explain their concerns allows the nurse
to gain a deeper understanding of the anxiety and shows that the nurse
is attentive and nonjudgmental. The other options dismiss the client’s
feelings, which can hinder rapport building.
6. A patient with a history of alcohol dependence is undergoing
detoxification. The nurse understands that which of the following is
the most common complication during alcohol withdrawal?
A. Severe hypoglycemia
B. Seizures
C. Pulmonary embolism
D. Hemorrhagic stroke
Answer: B. Seizures
Rationale: Seizures are a common complication of alcohol withdrawal,
occurring within the first 12 to 24 hours after the last drink. They are
potentially life-threatening and require close monitoring during
