Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A client with schizophrenia hears voices commanding harm to others. What is the nurse’s priority
action?
✔✔Ensure the client and environment are safe.
A client with depression refuses meals. What is the nurse’s best action?
✔✔Offer small, frequent, high-calorie foods the client can tolerate.
A client experiencing a panic attack states, “I feel like I’m going to die.” What should the nurse
do first?
✔✔Stay with the client and use a calm, reassuring presence.
A client taking lithium reports nausea, tremors, and unsteady gait. What should the nurse
suspect?
✔✔Signs of lithium toxicity.
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,A client says, “The FBI has placed cameras in my room.” What is the most therapeutic nursing
response?
✔✔“I understand this feels real for you, but I do not see any cameras.”
A client with obsessive-compulsive disorder spends hours checking locks. What is the best
nursing approach?
✔✔Allow the ritual but gradually set reasonable time limits.
A client with PTSD reports frequent flashbacks. What is the nurse’s priority intervention?
✔✔Assist the client to use grounding techniques.
A client in alcohol withdrawal suddenly becomes confused and agitated. What should the nurse
suspect?
✔✔Delirium tremens.
A client with bipolar disorder is overly talkative, restless, and distractible. What phase is the
client experiencing?
✔✔A manic episode.
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,A client with anorexia nervosa has a heart rate of 40 beats per minute. What is the priority
action?
✔✔Notify the healthcare provider immediately.
A client with depression states, “I have no purpose to live.” What should the nurse do first?
✔✔Assess the client’s risk of suicide.
A client prescribed clozapine develops a fever and sore throat. What is the nurse’s priority
intervention?
✔✔Obtain a white blood cell count.
A client in a psychiatric unit suddenly becomes physically aggressive. What is the nurse’s first
action?
✔✔Ensure the safety of all clients and staff.
A client with generalized anxiety disorder reports constant restlessness. What intervention should
the nurse use?
✔✔Teach deep breathing and relaxation exercises.
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, A client with schizophrenia is mute and maintains rigid posture for long periods. What condition
is suspected?
✔✔Catatonia.
A client prescribed sertraline states, “I feel better after three days. I don’t need this anymore.”
What is the nurse’s best response?
✔✔“It may take several weeks for the full effect. Do not stop taking it suddenly.”
A client with borderline personality disorder tells one nurse, “You are the only good nurse here.”
What behavior is this?
✔✔Splitting.
A client with depression refuses to participate in group therapy. What is the most therapeutic
nursing action?
✔✔Sit quietly with the client to convey presence.
A client reports muscle stiffness, high fever, and confusion after starting haloperidol. What
complication should the nurse suspect?
✔✔Neuroleptic malignant syndrome.
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