,1. A client with major depressive disorder has been withdrawn for several days. Today the client
is suddenly calm, eating meals, and giving away personal belongings. What is the nurse's
priority concern?
A) Improvement in mood indicating recovery
B) Medication effectiveness beginning to show
C) Imminent suicide risk
D) Social withdrawal resolving
Correct Answer: Imminent suicide risk
Rationale: Sudden calmness combined with giving away personal belongings are classic pre-
suicide warning signs . The client may have made a decision to end their life, and the apparent
improvement in mood can be misleading . This is a medical emergency requiring immediate
suicide risk assessment and implementation of safety precautions such as constant observation
.
2. A client states, "Sometimes I think everyone would be better off without me." What is the
nurse's best response?
A) "You shouldn't think that way about yourself."
B) "Are you thinking about killing yourself?"
C) "Many people feel this way when depressed."
D) "Let's talk about something positive."
Correct Answer: "Are you thinking about killing yourself?"
Rationale: Direct questioning about suicidal ideation does NOT increase suicide risk and is
required for accurate safety assessment . The nurse must ask directly about thoughts of self-
harm, intent, and plan . False reassurance and changing the subject are non-therapeutic and can
miss critical safety information .
,3. A patient hospitalized for bipolar disorder, manic episode, is pacing rapidly, speaking loudly,
and making inappropriate jokes. What is the most appropriate nursing intervention?
A) Allow the patient to continue pacing to expend energy
B) Place the patient in seclusion to protect others
C) Redirect the patient to a quiet area with minimal stimulation
D) Join in the jokes to build rapport
Correct Answer: Redirect the patient to a quiet area with minimal stimulation
Rationale: Clients in the manic phase require reduced stimulation to prevent escalation .
Redirecting to a quiet area and providing a structured environment with low stimuli helps
decrease agitation and promotes safety . A private room near the nursing station allows for
monitoring while minimizing interaction that could escalate mania .
4. A nurse is assessing a client who has been taking haloperidol for 3 months. The client has a
temperature of 39.5°C (103.4°F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which
condition should the nurse suspect?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome (NMS)
C) Tardive dyskinesia
D) Lithium toxicity
Correct Answer: Neuroleptic malignant syndrome (NMS)
Rationale: NMS is a life-threatening adverse effect of antipsychotic medications characterized by
muscle rigidity, high fever, autonomic instability (hypertension, tachycardia), and altered mental
status . This is a medical emergency requiring immediate discontinuation of the antipsychotic
, and supportive care . The classic presentation includes "lead-pipe" rigidity and elevated
temperature.
5. A client prescribed citalopram for depression reports feeling better after 2 weeks but is
frustrated that symptoms have not fully resolved. What is the most appropriate nursing
response?
A) "Let me call the provider to discuss changing your medication."
B) "Antidepressants often take 4 to 6 weeks to reach full effectiveness."
C) "You should stop taking the medication if it's not working."
D) "I will recommend adding another medication to help."
Correct Answer: "Antidepressants often take 4 to 6 weeks to reach full effectiveness."
Rationale: SSRIs like citalopram typically take 4 to 6 weeks (or longer after a dose adjustment) to
achieve their full therapeutic effect . The improvement in mood is a positive early sign, and the
nurse should provide this education to manage the client's expectations and encourage
medication adherence .
6. Which of the following findings are characteristic of tardive dyskinesia? Select all that apply.
A) Lip smacking
B) Pacing and restlessness
C) Fine tremors of the hands
D) Tongue protrusion
E) Facial grimacing
Correct Answer: Lip smacking, Tongue protrusion, Facial grimacing
is suddenly calm, eating meals, and giving away personal belongings. What is the nurse's
priority concern?
A) Improvement in mood indicating recovery
B) Medication effectiveness beginning to show
C) Imminent suicide risk
D) Social withdrawal resolving
Correct Answer: Imminent suicide risk
Rationale: Sudden calmness combined with giving away personal belongings are classic pre-
suicide warning signs . The client may have made a decision to end their life, and the apparent
improvement in mood can be misleading . This is a medical emergency requiring immediate
suicide risk assessment and implementation of safety precautions such as constant observation
.
2. A client states, "Sometimes I think everyone would be better off without me." What is the
nurse's best response?
A) "You shouldn't think that way about yourself."
B) "Are you thinking about killing yourself?"
C) "Many people feel this way when depressed."
D) "Let's talk about something positive."
Correct Answer: "Are you thinking about killing yourself?"
Rationale: Direct questioning about suicidal ideation does NOT increase suicide risk and is
required for accurate safety assessment . The nurse must ask directly about thoughts of self-
harm, intent, and plan . False reassurance and changing the subject are non-therapeutic and can
miss critical safety information .
,3. A patient hospitalized for bipolar disorder, manic episode, is pacing rapidly, speaking loudly,
and making inappropriate jokes. What is the most appropriate nursing intervention?
A) Allow the patient to continue pacing to expend energy
B) Place the patient in seclusion to protect others
C) Redirect the patient to a quiet area with minimal stimulation
D) Join in the jokes to build rapport
Correct Answer: Redirect the patient to a quiet area with minimal stimulation
Rationale: Clients in the manic phase require reduced stimulation to prevent escalation .
Redirecting to a quiet area and providing a structured environment with low stimuli helps
decrease agitation and promotes safety . A private room near the nursing station allows for
monitoring while minimizing interaction that could escalate mania .
4. A nurse is assessing a client who has been taking haloperidol for 3 months. The client has a
temperature of 39.5°C (103.4°F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which
condition should the nurse suspect?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome (NMS)
C) Tardive dyskinesia
D) Lithium toxicity
Correct Answer: Neuroleptic malignant syndrome (NMS)
Rationale: NMS is a life-threatening adverse effect of antipsychotic medications characterized by
muscle rigidity, high fever, autonomic instability (hypertension, tachycardia), and altered mental
status . This is a medical emergency requiring immediate discontinuation of the antipsychotic
, and supportive care . The classic presentation includes "lead-pipe" rigidity and elevated
temperature.
5. A client prescribed citalopram for depression reports feeling better after 2 weeks but is
frustrated that symptoms have not fully resolved. What is the most appropriate nursing
response?
A) "Let me call the provider to discuss changing your medication."
B) "Antidepressants often take 4 to 6 weeks to reach full effectiveness."
C) "You should stop taking the medication if it's not working."
D) "I will recommend adding another medication to help."
Correct Answer: "Antidepressants often take 4 to 6 weeks to reach full effectiveness."
Rationale: SSRIs like citalopram typically take 4 to 6 weeks (or longer after a dose adjustment) to
achieve their full therapeutic effect . The improvement in mood is a positive early sign, and the
nurse should provide this education to manage the client's expectations and encourage
medication adherence .
6. Which of the following findings are characteristic of tardive dyskinesia? Select all that apply.
A) Lip smacking
B) Pacing and restlessness
C) Fine tremors of the hands
D) Tongue protrusion
E) Facial grimacing
Correct Answer: Lip smacking, Tongue protrusion, Facial grimacing
