and Answers | Latest Version | 2025/2026
| Correct & Verified
What is the priority nursing action when a client reports hearing voices telling them to hurt
someone?
✔✔ Assess for the content of the hallucination and ensure the safety of others
What is the best way for a nurse to respond when a client with depression says, “I feel
hopeless”?
✔✔ Use therapeutic communication and say, “Tell me more about how you’re feeling.”
What is the most effective technique to use during the orientation phase of a therapeutic
relationship?
✔✔ Establish boundaries and build trust
Which finding indicates a positive response to antidepressant therapy?
✔✔ The client begins participating in group activities again
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,What is the nurse's priority when caring for a client in the manic phase of bipolar disorder?
✔✔ Reduce environmental stimuli and set consistent limits
What is an early sign of lithium toxicity?
✔✔ Fine hand tremors and nausea
What should a nurse do when a client with schizophrenia begins to pace and clench their fists?
✔✔ Offer a quiet space and attempt to de-escalate the situation
Which statement indicates a client is experiencing a delusion?
✔✔ “The government has placed a chip in my brain to monitor me.”
What action should the nurse take when a client with OCD repeatedly checks the door lock?
✔✔ Allow the behavior initially and gradually introduce coping techniques
What is the first nursing action when a client expresses a desire to end their life?
✔✔ Ask the client directly if they have a plan to harm themselves
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, Which dietary instruction should be given to a client taking phenelzine?
✔✔ Avoid foods high in tyramine such as aged cheese
What does it mean if a client with PTSD is hypervigilant?
✔✔ They are in a constant state of alertness and easily startled
What is a therapeutic way to respond to a client who is crying?
✔✔ Sit quietly and allow them to express emotions
What is the nurse’s role when a client refuses to take a prescribed antipsychotic medication?
✔✔ Explore the reason for refusal and provide education about the medication
Which finding should the nurse expect in a client experiencing a panic attack?
✔✔ Rapid breathing, chest tightness, and fear of dying
What is the goal of cognitive-behavioral therapy (CBT)?
✔✔ To identify and change negative thought patterns
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