,1. A patient with major depression has been in bed for two days without eating or bathing.
What is the most appropriate initial nursing action?
A) Allow the patient to rest until they feel ready.
B) Gently assist the patient with morning care and encourage small activity.
C) Ask the patient to explain why they do not want to get out of bed.
D) Offer the patient a choice about skipping breakfast.
Correct Answer: Gently assist the patient with morning care and encourage small activity.
Rationale: Patients with severe depression often lack the motivation and energy to perform
basic activities of daily living. Providing supportive assistance without judgment is therapeutic
and prevents further withdrawal . Open-ended "why" questions can be perceived as judgmental
and are unlikely to be helpful.
2. A patient tells the nurse, "I don't think I can go on anymore." What is the nurse's priority
action?
A) Tell the patient, "Everything will be fine."
B) Document the statement and continue the conversation.
C) Assess for suicidal ideation, including plan, intent, and means.
D) Leave the patient alone to process their feelings.
Correct Answer: Assess for suicidal ideation, including plan, intent, and means.
Rationale: Any statement suggesting hopelessness or suicidal thoughts requires immediate,
direct assessment . The nurse must ask about suicidal ideation, including whether the patient
has a specific plan, the means to carry it out, and their intent . This is a patient safety priority.
,3. A patient is admitted with schizophrenia and tells the nurse, "The voices are telling me to hurt
myself." What is the priority nursing action?
A) Ask the patient what the voices are saying and ensure a safe environment.
B) Tell the patient the voices are not real and to ignore them.
C) Administer an antipsychotic medication without further assessment.
D) Change the subject to distract the patient.
Correct Answer: Ask the patient what the voices are saying and ensure a safe environment.
Rationale: Command hallucinations can be dangerous, and the priority is to assess the content
to determine the risk of harm to self or others . Safety is the priority; ignoring or distracting the
patient does not address the potential danger, and arguing reinforces the hallucination.
4. A patient has generalized anxiety disorder and is prescribed buspirone. Which teaching
should the nurse provide?
A) "This medication will work immediately to relieve your anxiety."
B) "It may take 4 to 6 weeks to feel the full therapeutic effects."
C) "You can take an extra dose if you feel particularly anxious."
D) "This medication is a benzodiazepine and is habit-forming."
Correct Answer: "It may take 4 to 6 weeks to feel the full therapeutic effects."
Rationale: Buspirone is a non-sedating, non-habit-forming anxiolytic that can take 4-6 weeks to
reach full therapeutic efficacy . It is not a benzodiazepine and does not work immediately. It
should not be taken PRN for acute anxiety.
5. A patient with bipolar disorder is prescribed lithium. The nurse should instruct the patient to
maintain adequate intake of which substance to prevent toxicity?
, A) Sodium and fluids
B) Potassium and protein
C) Calcium and vitamin D
D) Iron and fiber
Correct Answer: Sodium and fluids
Rationale: Dehydration and low sodium levels increase lithium reabsorption and the risk of
toxicity . Consistent sodium and fluid intake help maintain stable lithium levels within the
narrow therapeutic range.
6. A patient taking an MAOI (monoamine oxidase inhibitor) for depression should be taught to
avoid which food?
A) Fresh apples
B) Aged cheese
C) Broiled chicken
D) Pasta
Correct Answer: Aged cheese
Rationale: MAOIs inhibit the breakdown of tyramine; consuming tyramine-rich foods can cause
a hypertensive crisis . Aged cheese, cured meats, fermented foods, and certain alcoholic
beverages are high in tyramine and must be strictly avoided.
7. A patient is experiencing signs of serotonin syndrome. Which finding is most characteristic?
A) Muscle rigidity, hyperthermia, and altered mental status
B) Hypothermia, bradycardia, and constipation
What is the most appropriate initial nursing action?
A) Allow the patient to rest until they feel ready.
B) Gently assist the patient with morning care and encourage small activity.
C) Ask the patient to explain why they do not want to get out of bed.
D) Offer the patient a choice about skipping breakfast.
Correct Answer: Gently assist the patient with morning care and encourage small activity.
Rationale: Patients with severe depression often lack the motivation and energy to perform
basic activities of daily living. Providing supportive assistance without judgment is therapeutic
and prevents further withdrawal . Open-ended "why" questions can be perceived as judgmental
and are unlikely to be helpful.
2. A patient tells the nurse, "I don't think I can go on anymore." What is the nurse's priority
action?
A) Tell the patient, "Everything will be fine."
B) Document the statement and continue the conversation.
C) Assess for suicidal ideation, including plan, intent, and means.
D) Leave the patient alone to process their feelings.
Correct Answer: Assess for suicidal ideation, including plan, intent, and means.
Rationale: Any statement suggesting hopelessness or suicidal thoughts requires immediate,
direct assessment . The nurse must ask about suicidal ideation, including whether the patient
has a specific plan, the means to carry it out, and their intent . This is a patient safety priority.
,3. A patient is admitted with schizophrenia and tells the nurse, "The voices are telling me to hurt
myself." What is the priority nursing action?
A) Ask the patient what the voices are saying and ensure a safe environment.
B) Tell the patient the voices are not real and to ignore them.
C) Administer an antipsychotic medication without further assessment.
D) Change the subject to distract the patient.
Correct Answer: Ask the patient what the voices are saying and ensure a safe environment.
Rationale: Command hallucinations can be dangerous, and the priority is to assess the content
to determine the risk of harm to self or others . Safety is the priority; ignoring or distracting the
patient does not address the potential danger, and arguing reinforces the hallucination.
4. A patient has generalized anxiety disorder and is prescribed buspirone. Which teaching
should the nurse provide?
A) "This medication will work immediately to relieve your anxiety."
B) "It may take 4 to 6 weeks to feel the full therapeutic effects."
C) "You can take an extra dose if you feel particularly anxious."
D) "This medication is a benzodiazepine and is habit-forming."
Correct Answer: "It may take 4 to 6 weeks to feel the full therapeutic effects."
Rationale: Buspirone is a non-sedating, non-habit-forming anxiolytic that can take 4-6 weeks to
reach full therapeutic efficacy . It is not a benzodiazepine and does not work immediately. It
should not be taken PRN for acute anxiety.
5. A patient with bipolar disorder is prescribed lithium. The nurse should instruct the patient to
maintain adequate intake of which substance to prevent toxicity?
, A) Sodium and fluids
B) Potassium and protein
C) Calcium and vitamin D
D) Iron and fiber
Correct Answer: Sodium and fluids
Rationale: Dehydration and low sodium levels increase lithium reabsorption and the risk of
toxicity . Consistent sodium and fluid intake help maintain stable lithium levels within the
narrow therapeutic range.
6. A patient taking an MAOI (monoamine oxidase inhibitor) for depression should be taught to
avoid which food?
A) Fresh apples
B) Aged cheese
C) Broiled chicken
D) Pasta
Correct Answer: Aged cheese
Rationale: MAOIs inhibit the breakdown of tyramine; consuming tyramine-rich foods can cause
a hypertensive crisis . Aged cheese, cured meats, fermented foods, and certain alcoholic
beverages are high in tyramine and must be strictly avoided.
7. A patient is experiencing signs of serotonin syndrome. Which finding is most characteristic?
A) Muscle rigidity, hyperthermia, and altered mental status
B) Hypothermia, bradycardia, and constipation
