Actual Q&A PDF | Fortis College
1. A nurse is teaching a client about the side effects of lithium. Which statement
indicates understanding?
A) "I should maintain a consistent sodium intake."
B) "I can take ibuprofen for headaches."
C) "I need to have my liver function checked regularly."
D) "A low-sodium diet will help the medication work better."
Correct Answer: "I should maintain a consistent sodium intake."
Rationale: Lithium levels are affected by sodium and fluid balance. Clients should
maintain consistent sodium and fluid intake to prevent toxicity. NSAIDs like ibuprofen
can increase lithium levels. Lithium requires monitoring of serum levels and
kidney/thyroid function, not primarily liver function. A low-sodium diet can increase
lithium levels and should be avoided.
2. A client with schizophrenia is experiencing command hallucinations. Which action
should the nurse take first?
A) Tell the client to ignore the voices.
B) Ask the client what the voices are telling them to do.
C) Administer a PRN antipsychotic immediately.
D) Isolate the client to reduce stimulation.
Correct Answer: Ask the client what the voices are telling them to do.
,Rationale: Command hallucinations may instruct the client to harm themselves or
others, so assessing the content is the priority. Telling the client to ignore the voices is
not therapeutic, administering medication without assessment may be premature, and
isolation may increase anxiety.
3. A nurse is assessing a client who has been diagnosed with bulimia nervosa. Which
finding is most concerning?
A) Binge eating followed by self-induced vomiting
B) Body mass index below 17
C) Severe restriction of food intake
D) Lack of interest in food
Correct Answer: Binge eating followed by self-induced vomiting
Rationale: Bulimia nervosa is characterized by recurrent episodes of binge eating
followed by compensatory behaviors such as self-induced vomiting, laxative use, or
excessive exercise. A BMI below 17 and severe restriction of food intake are
characteristic of anorexia nervosa. Lack of interest in food is not typical of bulimia.
4. A client with major depressive disorder is prescribed sertraline. Which statement
indicates understanding of the medication?
A) "I will take the medication in the morning to reduce insomnia."
B) "I should stop the medication if I feel better."
C) "I can drink alcohol in moderation."
D) "I will take the medication only when I feel sad."
Correct Answer: "I will take the medication in the morning to reduce insomnia."
, Rationale: Sertraline can cause insomnia, so it is often taken in the morning. The
medication should not be stopped abruptly, alcohol should be avoided, and it should be
taken consistently, not only when feeling sad.
5. A client with borderline personality disorder states, "You're the only nurse who
understands me. The others are all against me." Which response by the nurse is most
therapeutic?
A) "I appreciate that, but the entire team is here to support you equally."
B) "You shouldn't say negative things about the other nurses."
C) "I'm glad you feel that way; let's keep working together closely."
D) "Perhaps you should request a different primary nurse."
Correct Answer: "I appreciate that, but the entire team is here to support you
equally."
Rationale: This response acknowledges the client's feeling while reinforcing the team
approach, which prevents splitting and maintains professional boundaries. Agreeing
with the idealization or criticizing staff would reinforce splitting. Suggesting a different
nurse does not address the underlying issue.
6. A nurse is assessing a client for serotonin syndrome. Which finding is most
concerning?
A) Mild nausea
B) Agitation, hyperthermia, and clonus
C) Weight gain and sedation
D) Dry mouth and constipation
Correct Answer: Agitation, hyperthermia, and clonus