Health Nursing Study Guide, Original Practice
Questions & Answers, Comprehensive Assessment
Preparation, Psychiatric Nursing Review,
Therapeutic Communication, Mental Status
Examination, Anxiety & Trauma Disorders, Mood
Disorders, Bipolar Disorder, Depression,
Schizophrenia, Psychopharmacology, Substance Use
Disorders, Crisis Intervention, Suicide Prevention,
Patient Safety & NGN-Style Clinical Judgment
Question 1: A nurse is assessing a client who has been diagnosed with
antisocial personality disorder. Which of the following behavioral
characteristics should the nurse expect to find?
A. Excessive dependence on others for decision-making
B. A pattern of unstable and intense interpersonal relationships
C. Disregard for the rights of others and a lack of remorse
D. Acute sensitivity to criticism and social rejection
CORRECT ANSWER: C. Disregard for the rights of others and a lack of remorse
Rationale: Antisocial personality disorder is characterized by a pervasive pattern of
disregard for and violation of the rights of others, along with a lack of empathy and
remorse. Option A describes dependent personality disorder. Option B describes
borderline personality disorder. Option D describes avoidant personality disorder.
Question 2: A client with schizophrenia tells the nurse, "The government is
tracking me through the fillings in my teeth." Which term best describes this
statement?
A. Illusion
B. Delusion of persecution
C. Referential delusion
D. Hallucination
CORRECT ANSWER: B. Delusion of persecution
Rationale: A persecutory delusion involves the false belief that one is being targeted,
harassed, or followed by an external entity, such as the government. An illusion is a
misinterpretation of a real external stimulus. A referential delusion is the belief that
neutral events have personal meaning. A hallucination is a sensory perception without
an external stimulus.
,Question 3: A nurse is planning care for a client experiencing alcohol
withdrawal. Which of the following medications should the nurse anticipate
administering to prevent delirium tremens?
A. Disulfiram
B. Naltrexone
C. Chlordiazepoxide
D. Acamprosate
CORRECT ANSWER: C. Chlordiazepoxide
Rationale: Chlordiazepoxide, a benzodiazepine, is the standard medication for alcohol
withdrawal to prevent seizures and delirium tremens by central nervous system
depression. Disulfiram causes an adverse reaction to alcohol. Naltrexone and
acamprosate are used for relapse prevention, not acute withdrawal.
Question 4: A client is prescribed fluoxetine for major depressive disorder. The
nurse should include which of the following in the teaching plan?
A. "Take the medication with grapefruit juice to enhance absorption."
B. "The therapeutic effects of this medication will be seen in 1 to 2 days."
C. "Do not stop taking this medication abruptly to avoid withdrawal syndrome."
D. "Monitor for a sudden onset of fever and muscle rigidity."
CORRECT ANSWER: D. Monitor for a sudden onset of fever and muscle
rigidity.
Rationale: Fluoxetine, an SSRI, carries a risk of serotonin syndrome, which presents with
sudden onset of fever, muscle rigidity, and autonomic instability. Grapefruit juice is
contraindicated with many medications. Therapeutic effects take 4-6 weeks. SSRIs have
a long half-life and withdrawal is less abrupt than with other antidepressants, but abrupt
cessation can still cause discontinuation syndrome.
Question 5: A nurse is caring for a client with bipolar disorder who is
experiencing a manic episode. Which of the following interventions is the
highest priority?
A. Provide a structured, quiet environment with minimal stimuli
B. Engage the client in a competitive game to redirect energy
C. Offer high-calorie finger foods to maintain nutrition
D. Encourage the client to verbalize feelings about the hospitalization
CORRECT ANSWER: A. Provide a structured, quiet environment with minimal
stimuli
Rationale: The priority for a client in a manic episode is safety and decreasing stimuli to
prevent exhaustion and escalation. Competition should be avoided as it can increase
,agitation. While nutrition and verbalization are important, they are secondary to
reducing environmental stimuli to stabilize behavior.
Question 6: Which of the following assessment findings is a key indicator of
bulimia nervosa, as opposed to anorexia nervosa?
A. Amenorrhea for three months
B. Preoccupation with food and cooking
C. Normal or slightly above-normal body weight
D. Distorted body image
CORRECT ANSWER: C. Normal or slightly above-normal body weight
Rationale: Individuals with bulimia nervosa typically maintain a normal or slightly
above-normal weight due to the binge-purge cycle, whereas anorexia nervosa is
characterized by significantly low body weight. Amenorrhea is a hallmark of anorexia.
Both disorders involve a preoccupation with food and distorted body image.
Question 7: A nurse is providing education to a client prescribed lithium
carbonate. Which of the following symptoms should the nurse instruct the
client to report immediately?
A. Fine hand tremors and increased thirst
B. Nausea and mild diarrhea
C. Ataxia and blurred vision
D. Weight gain and dry mouth
CORRECT ANSWER: C. Ataxia and blurred vision
Rationale: Ataxia (loss of coordination) and blurred vision are signs of lithium toxicity,
which is a medical emergency. Fine tremors, increased thirst, mild nausea, diarrhea,
weight gain, and dry mouth are common side effects at therapeutic levels but are not
immediately life-threatening.
Question 8: A client with post-traumatic stress disorder (PTSD) reports
experiencing recurrent nightmares and intrusive thoughts about a traumatic
event. The nurse understands that these symptoms are primarily related to
which mechanism?
A. Suppression of the traumatic memory
B. Hyperarousal of the sympathetic nervous system
C. Hypersensitivity to external cues
D. Inability to integrate the traumatic event into memory
CORRECT ANSWER: D. Inability to integrate the traumatic event into memory
, Rationale: PTSD symptoms such as intrusive thoughts and nightmares are thought to be
due to the failure of the brain to properly process and integrate the traumatic event,
leading to its re-experiencing. This is associated with a dysregulated fear response and
hippocampal dysfunction.
Question 9: A nurse is assessing a client who is taking haloperidol. Which of
the following findings would indicate a potentially life-threatening adverse
effect requiring immediate intervention?
A. Akathisia
B. Dystonia
C. Neuroleptic malignant syndrome
D. Tardive dyskinesia
CORRECT ANSWER: C. Neuroleptic malignant syndrome
Rationale: Neuroleptic malignant syndrome (NMS) is a life-threatening complication of
antipsychotic medications characterized by severe muscle rigidity, hyperthermia,
autonomic instability, and elevated creatine kinase. Akathisia, dystonia, and tardive
dyskinesia are serious but not immediately life-threatening in the same acute sense.
Question 10: A client with generalized anxiety disorder reports difficulty
falling asleep and excessive worry. Which of the following nursing
interventions is most appropriate initially?
A. Encourage the client to remain in bed until sleep occurs
B. Administer a prescribed benzodiazepine as needed for sleep
C. Teach the client deep breathing and progressive muscle relaxation
D. Advise the client to sleep during the day to make up for lost sleep
CORRECT ANSWER: C. Teach the client deep breathing and progressive
muscle relaxation
Rationale: Non-pharmacological interventions such as relaxation techniques are first-line
interventions to manage anxiety and improve sleep. They are safe and promote self-
management. Medications should not be the initial or only intervention. Remaining in
bed can increase frustration, and day sleeping disrupts the sleep-wake cycle.
Question 11: A nurse is evaluating the effectiveness of a treatment plan for a
client with obsessive-compulsive disorder (OCD). Which of the following client
outcomes would indicate progress?
A. The client reports a decrease in the frequency of compulsions from 20 times to 5
times a day
B. The client verbalizes an understanding that the obsessions are realistic