Answers | Latest Version | 2025/2026 |
Correct & Verified
A client with schizophrenia says, “The FBI is tracking me through my phone.” What is the
nurse’s best response?
✔✔“It sounds like you are feeling frightened right now.”
A client is pacing and shouting loudly on the unit. What is the nurse’s priority action?
✔✔Approach calmly and ensure safety for all clients.
A client taking lithium reports diarrhea, tremors, and unsteady gait. What should the nurse
suspect?
✔✔Lithium toxicity.
A client states, “I hear voices telling me to hurt myself.” What should the nurse do first?
✔✔Assess the client’s risk and ensure immediate safety.
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,A client with depression refuses meals and isolates in the room. What is the best nursing
intervention?
✔✔Offer brief, supportive visits and encourage small, frequent meals.
A nurse observes a client sitting rigidly, not speaking, and resisting movement. What is this
behavior called?
✔✔Catatonia.
A client prescribed clozapine reports fever and sore throat. What should the nurse do
immediately?
✔✔Obtain a white blood cell count.
A client with OCD repeatedly checks the stove. What is the nurse’s best intervention?
✔✔Allow the behavior initially, then work to set limits gradually.
A client in alcohol withdrawal becomes tremulous and diaphoretic. What is the priority action?
✔✔Monitor vital signs and prepare to administer benzodiazepines.
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, A client says, “I’m worthless and I don’t want to live anymore.” What is the nurse’s first action?
✔✔Assess the client for suicide risk.
A client is experiencing rapid speech and flight of ideas. What disorder does this suggest?
✔✔Bipolar disorder in a manic phase.
A client insists that the nurse is part of a government plot. What is this symptom called?
✔✔Paranoid delusion.
A client with depression begins to attend community meetings after refusing previously. What
does this indicate?
✔✔Improvement in social functioning.
A client on fluoxetine develops agitation, sweating, and muscle rigidity. What should the nurse
suspect?
✔✔Serotonin syndrome.
A client sees a curtain moving and believes it is a person. What is this phenomenon?
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