1. Which of the following is the most important initial action for a
nurse to take when assessing a client who is exhibiting signs of
depression?
A) Provide the client with a detailed schedule for the day
B) Encourage the client to participate in a group activity
C) Ask the client directly about suicidal thoughts
D) Tell the client to think positively
Answer: C) Ask the client directly about suicidal thoughts
Rationale: The nurse's first priority is to assess the client's safety. Asking
directly about suicidal thoughts or plans helps to identify any
immediate risk and allows for timely intervention. It is important to
address these concerns without avoiding the topic.
2. A client is diagnosed with generalized anxiety disorder (GAD).
Which of the following is a common symptom of GAD?
A) Experiencing uncontrollable panic attacks
B) Obsessing over a specific phobia
C) Excessive worry and tension
D) Auditory hallucinations
Answer: C) Excessive worry and tension
Rationale: Generalized Anxiety Disorder is characterized by excessive,
uncontrollable worry about various events or activities. The worry is
often disproportionate to the actual situation and occurs most days for
at least six months.
,3. A nurse is working with a client diagnosed with schizophrenia. The
client says, "The government is watching me." What is the best
response by the nurse?
A) "That’s not true. The government is not watching you."
B) "Why do you think the government is watching you?"
C) "You are safe here. Let’s talk about something else."
D) "Tell me more about what the government is doing."
Answer: C) "You are safe here. Let’s talk about something else."
Rationale: It is important to validate the client’s feelings ("You are safe
here") while gently redirecting the conversation. Confronting or arguing
about the delusion may escalate the client's anxiety or defensive
behavior.
4. A nurse is planning care for a client with borderline personality
disorder. Which of the following interventions is most appropriate?
A) Set clear and consistent boundaries
B) Allow the client to make all decisions independently
C) Encourage the client to form multiple romantic relationships
D) Ignore the client's impulsive behaviors
Answer: A) Set clear and consistent boundaries
Rationale: Clients with borderline personality disorder often experience
difficulty with emotional regulation and may engage in manipulative or
impulsive behaviors. Consistent and clear boundaries help reduce
confusion and improve the client’s sense of security.
5. Which of the following medications is most commonly used to treat
major depressive disorder (MDD)?
, A) Diazepam
B) Fluoxetine
C) Haloperidol
D) Lorazepam
Answer: B) Fluoxetine
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI)
commonly prescribed for major depressive disorder. It works by
increasing serotonin levels in the brain, which helps improve mood and
anxiety.
6. A nurse is caring for a client with anorexia nervosa. Which of the
following is an important intervention to promote weight gain in this
client?
A) Encourage the client to eat three large meals daily
B) Focus on the client's physical appearance during meals
C) Provide small, frequent meals with high-calorie snacks
D) Administer anti-anxiety medication before meals
Answer: C) Provide small, frequent meals with high-calorie snacks
Rationale: Clients with anorexia nervosa may be overwhelmed by large
meals. Small, frequent meals and high-calorie snacks are more
manageable and help the client gradually increase their caloric intake.
Additionally, focusing on non-food-related topics helps prevent the
client from becoming anxious or resistant during meals.
7. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following statements by the client would suggest
the need for further assessment?
nurse to take when assessing a client who is exhibiting signs of
depression?
A) Provide the client with a detailed schedule for the day
B) Encourage the client to participate in a group activity
C) Ask the client directly about suicidal thoughts
D) Tell the client to think positively
Answer: C) Ask the client directly about suicidal thoughts
Rationale: The nurse's first priority is to assess the client's safety. Asking
directly about suicidal thoughts or plans helps to identify any
immediate risk and allows for timely intervention. It is important to
address these concerns without avoiding the topic.
2. A client is diagnosed with generalized anxiety disorder (GAD).
Which of the following is a common symptom of GAD?
A) Experiencing uncontrollable panic attacks
B) Obsessing over a specific phobia
C) Excessive worry and tension
D) Auditory hallucinations
Answer: C) Excessive worry and tension
Rationale: Generalized Anxiety Disorder is characterized by excessive,
uncontrollable worry about various events or activities. The worry is
often disproportionate to the actual situation and occurs most days for
at least six months.
,3. A nurse is working with a client diagnosed with schizophrenia. The
client says, "The government is watching me." What is the best
response by the nurse?
A) "That’s not true. The government is not watching you."
B) "Why do you think the government is watching you?"
C) "You are safe here. Let’s talk about something else."
D) "Tell me more about what the government is doing."
Answer: C) "You are safe here. Let’s talk about something else."
Rationale: It is important to validate the client’s feelings ("You are safe
here") while gently redirecting the conversation. Confronting or arguing
about the delusion may escalate the client's anxiety or defensive
behavior.
4. A nurse is planning care for a client with borderline personality
disorder. Which of the following interventions is most appropriate?
A) Set clear and consistent boundaries
B) Allow the client to make all decisions independently
C) Encourage the client to form multiple romantic relationships
D) Ignore the client's impulsive behaviors
Answer: A) Set clear and consistent boundaries
Rationale: Clients with borderline personality disorder often experience
difficulty with emotional regulation and may engage in manipulative or
impulsive behaviors. Consistent and clear boundaries help reduce
confusion and improve the client’s sense of security.
5. Which of the following medications is most commonly used to treat
major depressive disorder (MDD)?
, A) Diazepam
B) Fluoxetine
C) Haloperidol
D) Lorazepam
Answer: B) Fluoxetine
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI)
commonly prescribed for major depressive disorder. It works by
increasing serotonin levels in the brain, which helps improve mood and
anxiety.
6. A nurse is caring for a client with anorexia nervosa. Which of the
following is an important intervention to promote weight gain in this
client?
A) Encourage the client to eat three large meals daily
B) Focus on the client's physical appearance during meals
C) Provide small, frequent meals with high-calorie snacks
D) Administer anti-anxiety medication before meals
Answer: C) Provide small, frequent meals with high-calorie snacks
Rationale: Clients with anorexia nervosa may be overwhelmed by large
meals. Small, frequent meals and high-calorie snacks are more
manageable and help the client gradually increase their caloric intake.
Additionally, focusing on non-food-related topics helps prevent the
client from becoming anxious or resistant during meals.
7. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following statements by the client would suggest
the need for further assessment?
