1. Which of the following is a therapeutic communication
technique?
A. Offering your opinion
B. Giving advice
C. Asking open-ended questions
D. Asking "why" questions
Answer: C
Rationale: Open-ended questions encourage the client to express
their thoughts and feelings without bias or influence, which is key in
therapeutic communication.
2. A client with anorexia nervosa has a BMI of 14.5. Which is
the priority nursing intervention?
A. Monitor daily caloric intake and weight
B. Discuss body image perceptions
C. Encourage participation in group therapy
D. Promote exercise to improve muscle tone
Answer: A
Rationale: Clients with severe anorexia require close monitoring of
caloric intake and weight to address the immediate risk of
malnutrition and related complications.
3. A nurse is assessing a client with conversion disorder. What
is an expected finding?
A. Reports of pain without a physiological basis
B. Neurological symptoms inconsistent with medical findings
C. Preoccupation with having a serious illness
D. Exaggerated fear of developing a medical condition
Answer: B
Rationale: Conversion disorder involves neurological symptoms
(e.g., paralysis, blindness) that lack a medical explanation.
4. What is the priority nursing intervention for a client with
suicidal ideation?
A. Establish a no-suicide contract
B. Administer antidepressant medication
C. Conduct a thorough risk assessment
,D. Monitor the client for changes in behavior
Answer: C
Rationale: Conducting a risk assessment is the first step in
determining the severity of the client’s suicidal ideation and planning
appropriate interventions.
5. Which of the following interventions is appropriate for a
client with delirium?
A. Provide a stimulating environment
B. Allow the client to sleep during the day
C. Reorient the client to time and place frequently
D. Encourage the client to focus on abstract concepts
Answer: C
Rationale: Frequent reorientation helps reduce confusion and
anxiety in clients experiencing delirium.
6. Which defense mechanism is a client using when they state,
"I failed the test because the teacher is unfair"?
A. Denial
B. Projection
C. Rationalization
D. Displacement
Answer: C
Rationale: Rationalization involves justifying actions or decisions to
avoid facing underlying anxiety.
7. A nurse is caring for a client with schizophrenia who is
experiencing auditory hallucinations. Which intervention
should the nurse use to address this symptom?
A. Tell the client that the voices are not real
B. Ask the client what the voices are saying
C. Suggest the client listen to music
D. Encourage the client to focus on reality-based topics
Answer: B
Rationale: Understanding what the voices are saying helps the
nurse assess the content for any potential danger to the client or
others. This is a priority before attempting other interventions.
8. A client taking lithium carbonate for bipolar disorder
, reports nausea and hand tremors. What should the nurse do
first?
A. Reassure the client these are expected side effects
B. Hold the next dose of lithium
C. Check the client’s serum lithium level
D. Encourage the client to increase fluid intake
Answer: C
Rationale: Nausea and tremors can indicate lithium toxicity. Serum
levels should be assessed to determine the appropriate course of
action.
9. A nurse is caring for a client experiencing severe anxiety.
Which intervention is most appropriate?
A. Encourage decision-making to regain control
B. Provide detailed explanations about the situation
C. Remain with the client and ensure a safe environment
D. Leave the client alone to promote self-reflection
Answer: C
Rationale: Clients with severe anxiety need immediate support and
reassurance to feel safe.
10. A client is prescribed disulfiram for alcohol use disorder.
Which of the following instructions should the nurse provide?
A. "You can drink alcohol in moderation while taking this
medication."
B. "Avoid alcohol-containing products like mouthwash and
aftershave."
C. "Stop taking the medication if you experience nausea."
D. "The medication will eliminate cravings for alcohol."
Answer: B
Rationale: Disulfiram reacts with even small amounts of alcohol,
including in common products, causing adverse effects.
11. A nurse is caring for a client with borderline personality
disorder who exhibits self-harm behaviors. Which nursing
action is appropriate?
A. Offer sympathy when the client self-harms
B. Encourage the client to join a support group
C. Establish clear professional boundaries
technique?
A. Offering your opinion
B. Giving advice
C. Asking open-ended questions
D. Asking "why" questions
Answer: C
Rationale: Open-ended questions encourage the client to express
their thoughts and feelings without bias or influence, which is key in
therapeutic communication.
2. A client with anorexia nervosa has a BMI of 14.5. Which is
the priority nursing intervention?
A. Monitor daily caloric intake and weight
B. Discuss body image perceptions
C. Encourage participation in group therapy
D. Promote exercise to improve muscle tone
Answer: A
Rationale: Clients with severe anorexia require close monitoring of
caloric intake and weight to address the immediate risk of
malnutrition and related complications.
3. A nurse is assessing a client with conversion disorder. What
is an expected finding?
A. Reports of pain without a physiological basis
B. Neurological symptoms inconsistent with medical findings
C. Preoccupation with having a serious illness
D. Exaggerated fear of developing a medical condition
Answer: B
Rationale: Conversion disorder involves neurological symptoms
(e.g., paralysis, blindness) that lack a medical explanation.
4. What is the priority nursing intervention for a client with
suicidal ideation?
A. Establish a no-suicide contract
B. Administer antidepressant medication
C. Conduct a thorough risk assessment
,D. Monitor the client for changes in behavior
Answer: C
Rationale: Conducting a risk assessment is the first step in
determining the severity of the client’s suicidal ideation and planning
appropriate interventions.
5. Which of the following interventions is appropriate for a
client with delirium?
A. Provide a stimulating environment
B. Allow the client to sleep during the day
C. Reorient the client to time and place frequently
D. Encourage the client to focus on abstract concepts
Answer: C
Rationale: Frequent reorientation helps reduce confusion and
anxiety in clients experiencing delirium.
6. Which defense mechanism is a client using when they state,
"I failed the test because the teacher is unfair"?
A. Denial
B. Projection
C. Rationalization
D. Displacement
Answer: C
Rationale: Rationalization involves justifying actions or decisions to
avoid facing underlying anxiety.
7. A nurse is caring for a client with schizophrenia who is
experiencing auditory hallucinations. Which intervention
should the nurse use to address this symptom?
A. Tell the client that the voices are not real
B. Ask the client what the voices are saying
C. Suggest the client listen to music
D. Encourage the client to focus on reality-based topics
Answer: B
Rationale: Understanding what the voices are saying helps the
nurse assess the content for any potential danger to the client or
others. This is a priority before attempting other interventions.
8. A client taking lithium carbonate for bipolar disorder
, reports nausea and hand tremors. What should the nurse do
first?
A. Reassure the client these are expected side effects
B. Hold the next dose of lithium
C. Check the client’s serum lithium level
D. Encourage the client to increase fluid intake
Answer: C
Rationale: Nausea and tremors can indicate lithium toxicity. Serum
levels should be assessed to determine the appropriate course of
action.
9. A nurse is caring for a client experiencing severe anxiety.
Which intervention is most appropriate?
A. Encourage decision-making to regain control
B. Provide detailed explanations about the situation
C. Remain with the client and ensure a safe environment
D. Leave the client alone to promote self-reflection
Answer: C
Rationale: Clients with severe anxiety need immediate support and
reassurance to feel safe.
10. A client is prescribed disulfiram for alcohol use disorder.
Which of the following instructions should the nurse provide?
A. "You can drink alcohol in moderation while taking this
medication."
B. "Avoid alcohol-containing products like mouthwash and
aftershave."
C. "Stop taking the medication if you experience nausea."
D. "The medication will eliminate cravings for alcohol."
Answer: B
Rationale: Disulfiram reacts with even small amounts of alcohol,
including in common products, causing adverse effects.
11. A nurse is caring for a client with borderline personality
disorder who exhibits self-harm behaviors. Which nursing
action is appropriate?
A. Offer sympathy when the client self-harms
B. Encourage the client to join a support group
C. Establish clear professional boundaries
