1. Question:
A client diagnosed with schizophrenia is experiencing auditory
hallucinations. The nurse should respond in which way?
A) "I hear the voices too."
B) "You’re just imagining things, try to relax."
C) "What are the voices telling you?"
D) "The voices aren’t real, don’t listen to them."
Answer: C) "What are the voices telling you?"
Rationale:
When a client is experiencing auditory hallucinations, it is important to
acknowledge the experience without validating or denying the
hallucination. Asking the client to describe the content of the voices
helps assess the severity of the hallucinations and can provide insight
into the client's condition.
2. Question:
A nurse is planning care for a client with major depressive disorder.
Which of the following interventions should be prioritized?
A) Encouraging the client to take frequent walks
B) Asking the client about their social support network
C) Assessing the client for suicidal ideation
D) Encouraging the client to participate in group therapy
Answer: C) Assessing the client for suicidal ideation
Rationale:
The highest priority for a client with major depressive disorder is
assessing for suicidal ideation. Depression can increase the risk of
,suicide, so the nurse should first assess the client’s safety before
implementing other interventions.
3. Question:
A nurse is assessing a client who has recently been diagnosed with
bipolar disorder. The client displays rapid speech, grandiose thoughts,
and impulsivity. The nurse recognizes that the client is most likely
experiencing:
A) Depressive episode
B) Hypomania
C) Mania
D) Mixed episode
Answer: C) Mania
Rationale:
Mania is characterized by elevated mood, rapid speech, grandiose
thoughts, and impulsivity. This is distinct from hypomania, which is a
less severe form of mania. A depressive episode would not involve
these symptoms, and a mixed episode involves both manic and
depressive symptoms.
4. Question:
A nurse is providing teaching to a client prescribed a selective serotonin
reuptake inhibitor (SSRI) for depression. The nurse should instruct the
client to report which of the following symptoms immediately?
A) Decreased appetite
B) Insomnia
, C) Increased thoughts of suicide
D) Drowsiness
Answer: C) Increased thoughts of suicide
Rationale:
SSRIs can initially increase the risk of suicide, especially in children,
adolescents, and young adults. Clients should be instructed to report
any increase in suicidal thoughts or behaviors immediately. Other
symptoms listed are not as urgent in the context of SSRI use.
5. Question:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following interventions should the nurse prioritize?
A) Encouraging the client to identify triggers of anxiety
B) Offering distractions to minimize anxiety
C) Teaching relaxation techniques to reduce anxiety
D) Administering anti-anxiety medications as prescribed
Answer: D) Administering anti-anxiety medications as prescribed
Rationale:
The immediate priority for a client with GAD is to help reduce anxiety
symptoms. While other interventions are helpful long-term,
administering prescribed anti-anxiety medications will provide
immediate relief and stabilize the client before other therapeutic
interventions can be implemented.
6. Question:
A nurse is caring for a client with post-traumatic stress disorder (PTSD).
The nurse should prioritize which of the following actions?
A client diagnosed with schizophrenia is experiencing auditory
hallucinations. The nurse should respond in which way?
A) "I hear the voices too."
B) "You’re just imagining things, try to relax."
C) "What are the voices telling you?"
D) "The voices aren’t real, don’t listen to them."
Answer: C) "What are the voices telling you?"
Rationale:
When a client is experiencing auditory hallucinations, it is important to
acknowledge the experience without validating or denying the
hallucination. Asking the client to describe the content of the voices
helps assess the severity of the hallucinations and can provide insight
into the client's condition.
2. Question:
A nurse is planning care for a client with major depressive disorder.
Which of the following interventions should be prioritized?
A) Encouraging the client to take frequent walks
B) Asking the client about their social support network
C) Assessing the client for suicidal ideation
D) Encouraging the client to participate in group therapy
Answer: C) Assessing the client for suicidal ideation
Rationale:
The highest priority for a client with major depressive disorder is
assessing for suicidal ideation. Depression can increase the risk of
,suicide, so the nurse should first assess the client’s safety before
implementing other interventions.
3. Question:
A nurse is assessing a client who has recently been diagnosed with
bipolar disorder. The client displays rapid speech, grandiose thoughts,
and impulsivity. The nurse recognizes that the client is most likely
experiencing:
A) Depressive episode
B) Hypomania
C) Mania
D) Mixed episode
Answer: C) Mania
Rationale:
Mania is characterized by elevated mood, rapid speech, grandiose
thoughts, and impulsivity. This is distinct from hypomania, which is a
less severe form of mania. A depressive episode would not involve
these symptoms, and a mixed episode involves both manic and
depressive symptoms.
4. Question:
A nurse is providing teaching to a client prescribed a selective serotonin
reuptake inhibitor (SSRI) for depression. The nurse should instruct the
client to report which of the following symptoms immediately?
A) Decreased appetite
B) Insomnia
, C) Increased thoughts of suicide
D) Drowsiness
Answer: C) Increased thoughts of suicide
Rationale:
SSRIs can initially increase the risk of suicide, especially in children,
adolescents, and young adults. Clients should be instructed to report
any increase in suicidal thoughts or behaviors immediately. Other
symptoms listed are not as urgent in the context of SSRI use.
5. Question:
A nurse is caring for a client with generalized anxiety disorder (GAD).
Which of the following interventions should the nurse prioritize?
A) Encouraging the client to identify triggers of anxiety
B) Offering distractions to minimize anxiety
C) Teaching relaxation techniques to reduce anxiety
D) Administering anti-anxiety medications as prescribed
Answer: D) Administering anti-anxiety medications as prescribed
Rationale:
The immediate priority for a client with GAD is to help reduce anxiety
symptoms. While other interventions are helpful long-term,
administering prescribed anti-anxiety medications will provide
immediate relief and stabilize the client before other therapeutic
interventions can be implemented.
6. Question:
A nurse is caring for a client with post-traumatic stress disorder (PTSD).
The nurse should prioritize which of the following actions?
