Galen College of Nursing
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1. A nurse is assessing a client who states, “I just don’t care about
anything anymore.” Which of the following is the priority nursing
action?
A. Ask the client about suicidal ideation.
B. Encourage the client to participate in group therapy.
C. Assess the client’s vital signs.
D. Administer a prescribed antidepressant.
Answer: A
Rationale: When a client expresses feelings of hopelessness or
apathy, the priority is to assess for suicide risk. Patient safety is
always the primary concern in mental health nursing before
addressing other needs or interventions.
2. A client is experiencing a panic attack. Which of the following
actions should the nurse take first?
A. Administer a PRN anxiolytic.
B. Guide the client to take slow, deep breaths.
C. Escort the client to a quiet environment.
D. Call the provider for an order.
Answer: C
Rationale: During a panic attack, the client is easily overwhelmed by
stimuli. The first action is to move the client to a quiet, low-stimulus
environment to reduce anxiety. Then, breathing techniques or
medication can be utilized.
3. A nurse is caring for a client with major depressive disorder.
Which communication technique is being used when the nurse
states, “Tell me more about how you are feeling today”?
A. Focusing
B. Broad opening
,C. Reflection
D. Restating
Answer: B
Rationale: A broad opening allows the client to take the initiative in
introducing the topic and directs the conversation to whatever they
feel is most important.
4. Which of the following statements by a client indicates a non-
adherence to prescribed lithium therapy?
A. “I drink about 2 liters of water every day.”
B. “I have stopped using salt substitutes on my food.”
C. “I take my medication with a glass of milk every morning.”
D. “I stopped taking my medication because I felt fine.”
Answer: D
Rationale: Stopping lithium abruptly can lead to a relapse of bipolar
symptoms. Clients should never stop taking lithium without
consulting their provider, even if they feel well.
5. A nurse is obtaining a health history from a client suspected of
having generalized anxiety disorder (GAD). Which of the following
findings is characteristic of GAD?
A. Excessive worry about routine activities for at least 6 months.
B. Sudden onset of intense fear lasting 10 minutes.
C. Avoidance of social situations due to fear of scrutiny.
D. Flashbacks to a traumatic event.
Answer: A
Rationale: GAD is characterized by excessive, uncontrollable worry
about routine life events occurring more days than not for at least 6
months.
6. A client with schizophrenia says, “The birds are flying in the sky
because the government is watching us.” This statement is an
example of which alteration in thought?
A. Delusion of persecution
, B. Somatic delusion
C. Loose association
D. Idea of reference
Answer: C
Rationale: The client is connecting two unrelated concepts (birds
flying and government watching) without a logical bridge, which is
known as loose association.
7. A client is prescribed fluoxetine (Prozac) for depression. The
nurse should monitor the client for which life-threatening
complication?
A. Neuroleptic malignant syndrome (NMS)
B. Serotonin syndrome
C. Tardive dyskinesia
D. Hypertensive crisis
Answer: B
Rationale: Serotonin syndrome can occur with SSRIs, especially if
combined with other serotonergic drugs. Symptoms include
hyperthermia, agitation, tremors, and hyperreflexia.
8. Which of the following defense mechanisms involves the client
attributing their own unacceptable feelings to another person?
A. Denial
B. Projection
C. Displacement
D. Repression
Answer: B
Rationale: Projection is the misattribution of a person's undesired
feelings or impulses onto another person.
9. A nurse is caring for a client in the manic phase of bipolar
disorder. Which nursing intervention is the highest priority?
A. Encourage the client to participate in unit activities.
B. Provide the client with a high-calorie, high-protein diet.