1. A nurse is caring for a client with major depressive disorder. Which
of the following should the nurse include in the plan of care to address
the client's safety needs?
A) Encourage the client to participate in group therapy
B) Remind the client of the importance of following the medication
regimen
C) Continuously monitor the client for suicidal thoughts or behaviors
D) Allow the client to choose their daily activities
Answer: C) Continuously monitor the client for suicidal thoughts or
behaviors
Rationale: Clients with major depressive disorder are at increased risk
for suicidal thoughts and behaviors. Continuous monitoring for suicidal
ideation is essential to prevent harm and ensure safety. While
medication adherence (B) and group therapy (A) are important, the
priority in managing depression is ensuring the client's safety.
2. A nurse is caring for a client diagnosed with schizophrenia who is
displaying disorganized speech. Which statement by the nurse would
be most appropriate?
A) "I know you're feeling confused, but try to focus on the
conversation."
B) "Let's take a break and discuss this later when you're feeling more
organized."
C) "Can you repeat that in a way that's easier to understand?"
D) "You need to speak more clearly so I can understand you."
Answer: C) "Can you repeat that in a way that's easier to
understand?"
,Rationale: Clients with schizophrenia may experience disorganized
speech as part of their symptoms. It's important for the nurse to ask the
client to repeat themselves in a way that's easier to understand,
showing empathy and providing the opportunity for clearer
communication. The other options are either dismissive or do not
address the disorganized speech directly.
3. A client with anxiety disorder is prescribed lorazepam (Ativan) as a
short-term medication. Which statement by the nurse is most
appropriate when teaching the client about this medication?
A) "You should take this medication only when you're feeling anxious."
B) "This medication may cause drowsiness, so avoid driving or operating
heavy machinery."
C) "You can stop taking the medication as soon as you feel better."
D) "Take this medication with food to avoid nausea."
Answer: B) "This medication may cause drowsiness, so avoid driving
or operating heavy machinery."
Rationale: Lorazepam is a benzodiazepine that can cause drowsiness
and impair coordination, so it is crucial for the nurse to educate the
client about avoiding activities that require alertness, such as driving.
The other statements are not appropriate for this type of medication.
The medication should not be stopped abruptly (C) or used only on an
as-needed basis for anxiety (A), and food is not necessary to avoid
nausea (D).
4. A nurse is assessing a client with post-traumatic stress disorder
(PTSD). Which of the following symptoms should the nurse expect to
find in this client?
,A) Hypervigilance and exaggerated startle response
B) Delusions and auditory hallucinations
C) Obsessive thoughts and compulsive behaviors
D) Periods of manic behavior and increased energy
Answer: A) Hypervigilance and exaggerated startle response
Rationale: Hypervigilance (excessive alertness) and an exaggerated
startle response are common symptoms of PTSD, resulting from the
trauma the client has experienced. Delusions and auditory
hallucinations (B) are more characteristic of schizophrenia, obsessive-
compulsive behavior (C) is associated with obsessive-compulsive
disorder, and manic behavior (D) is seen in bipolar disorder.
5. A nurse is preparing to administer a psychotropic medication to a
client with bipolar disorder. The client reports feeling excessively
energetic and is talking rapidly. What action should the nurse take?
A) Administer the prescribed medication as ordered.
B) Withhold the medication and notify the healthcare provider.
C) Provide a quiet environment and allow the client to rest.
D) Encourage the client to participate in group therapy immediately.
Answer: B) Withhold the medication and notify the healthcare
provider.
Rationale: The client’s symptoms of excessive energy and rapid speech
suggest they may be in a manic episode. In this case, it’s important to
notify the healthcare provider to reassess the treatment plan.
Administering medication without addressing the potential for a manic
episode (A) could be unsafe. Providing rest (C) is helpful, but it doesn’t
address the need for immediate reassessment. Group therapy (D) is
beneficial, but it may not be the first priority in this situation.
, 6. A nurse is caring for a client diagnosed with borderline personality
disorder (BPD). Which behavior is most characteristic of this disorder?
A) Intense fear of abandonment
B) Obsessive thoughts and compulsive behaviors
C) Paranoia and distrust of others
D) Frequent manic episodes
Answer: A) Intense fear of abandonment
Rationale: Clients with borderline personality disorder often experience
an intense fear of abandonment and may have difficulty maintaining
stable relationships. This leads to emotional instability and impulsive
behaviors. The other options (B, C, D) are more characteristic of
obsessive-compulsive disorder, paranoid personality disorder, and
bipolar disorder, respectively.
7. A nurse is discussing the therapeutic communication techniques
with a group of nursing students. Which statement by a student
indicates a need for further teaching?
A) "I should provide a quiet environment for clients who are agitated."
B) "I should reflect on the feelings expressed by the client."
C) "I should use open-ended questions to encourage client dialogue."
D) "I should tell the client to stop feeling upset to make them feel
better."
Answer: D) "I should tell the client to stop feeling upset to make them
feel better."
Rationale: Telling a client to stop feeling upset minimizes their emotions
and dismisses their experience, which is not therapeutic. Instead,
of the following should the nurse include in the plan of care to address
the client's safety needs?
A) Encourage the client to participate in group therapy
B) Remind the client of the importance of following the medication
regimen
C) Continuously monitor the client for suicidal thoughts or behaviors
D) Allow the client to choose their daily activities
Answer: C) Continuously monitor the client for suicidal thoughts or
behaviors
Rationale: Clients with major depressive disorder are at increased risk
for suicidal thoughts and behaviors. Continuous monitoring for suicidal
ideation is essential to prevent harm and ensure safety. While
medication adherence (B) and group therapy (A) are important, the
priority in managing depression is ensuring the client's safety.
2. A nurse is caring for a client diagnosed with schizophrenia who is
displaying disorganized speech. Which statement by the nurse would
be most appropriate?
A) "I know you're feeling confused, but try to focus on the
conversation."
B) "Let's take a break and discuss this later when you're feeling more
organized."
C) "Can you repeat that in a way that's easier to understand?"
D) "You need to speak more clearly so I can understand you."
Answer: C) "Can you repeat that in a way that's easier to
understand?"
,Rationale: Clients with schizophrenia may experience disorganized
speech as part of their symptoms. It's important for the nurse to ask the
client to repeat themselves in a way that's easier to understand,
showing empathy and providing the opportunity for clearer
communication. The other options are either dismissive or do not
address the disorganized speech directly.
3. A client with anxiety disorder is prescribed lorazepam (Ativan) as a
short-term medication. Which statement by the nurse is most
appropriate when teaching the client about this medication?
A) "You should take this medication only when you're feeling anxious."
B) "This medication may cause drowsiness, so avoid driving or operating
heavy machinery."
C) "You can stop taking the medication as soon as you feel better."
D) "Take this medication with food to avoid nausea."
Answer: B) "This medication may cause drowsiness, so avoid driving
or operating heavy machinery."
Rationale: Lorazepam is a benzodiazepine that can cause drowsiness
and impair coordination, so it is crucial for the nurse to educate the
client about avoiding activities that require alertness, such as driving.
The other statements are not appropriate for this type of medication.
The medication should not be stopped abruptly (C) or used only on an
as-needed basis for anxiety (A), and food is not necessary to avoid
nausea (D).
4. A nurse is assessing a client with post-traumatic stress disorder
(PTSD). Which of the following symptoms should the nurse expect to
find in this client?
,A) Hypervigilance and exaggerated startle response
B) Delusions and auditory hallucinations
C) Obsessive thoughts and compulsive behaviors
D) Periods of manic behavior and increased energy
Answer: A) Hypervigilance and exaggerated startle response
Rationale: Hypervigilance (excessive alertness) and an exaggerated
startle response are common symptoms of PTSD, resulting from the
trauma the client has experienced. Delusions and auditory
hallucinations (B) are more characteristic of schizophrenia, obsessive-
compulsive behavior (C) is associated with obsessive-compulsive
disorder, and manic behavior (D) is seen in bipolar disorder.
5. A nurse is preparing to administer a psychotropic medication to a
client with bipolar disorder. The client reports feeling excessively
energetic and is talking rapidly. What action should the nurse take?
A) Administer the prescribed medication as ordered.
B) Withhold the medication and notify the healthcare provider.
C) Provide a quiet environment and allow the client to rest.
D) Encourage the client to participate in group therapy immediately.
Answer: B) Withhold the medication and notify the healthcare
provider.
Rationale: The client’s symptoms of excessive energy and rapid speech
suggest they may be in a manic episode. In this case, it’s important to
notify the healthcare provider to reassess the treatment plan.
Administering medication without addressing the potential for a manic
episode (A) could be unsafe. Providing rest (C) is helpful, but it doesn’t
address the need for immediate reassessment. Group therapy (D) is
beneficial, but it may not be the first priority in this situation.
, 6. A nurse is caring for a client diagnosed with borderline personality
disorder (BPD). Which behavior is most characteristic of this disorder?
A) Intense fear of abandonment
B) Obsessive thoughts and compulsive behaviors
C) Paranoia and distrust of others
D) Frequent manic episodes
Answer: A) Intense fear of abandonment
Rationale: Clients with borderline personality disorder often experience
an intense fear of abandonment and may have difficulty maintaining
stable relationships. This leads to emotional instability and impulsive
behaviors. The other options (B, C, D) are more characteristic of
obsessive-compulsive disorder, paranoid personality disorder, and
bipolar disorder, respectively.
7. A nurse is discussing the therapeutic communication techniques
with a group of nursing students. Which statement by a student
indicates a need for further teaching?
A) "I should provide a quiet environment for clients who are agitated."
B) "I should reflect on the feelings expressed by the client."
C) "I should use open-ended questions to encourage client dialogue."
D) "I should tell the client to stop feeling upset to make them feel
better."
Answer: D) "I should tell the client to stop feeling upset to make them
feel better."
Rationale: Telling a client to stop feeling upset minimizes their emotions
and dismisses their experience, which is not therapeutic. Instead,
