1. A nurse is caring for a client with generalized anxiety disorder
(GAD). Which of the following is the most appropriate intervention to
reduce anxiety in the client?
A) Encouraging the client to confront their fear B) Administering a
benzodiazepine as prescribed C) Encouraging the client to avoid
stressful situations D) Providing a quiet and calm environment
Answer: D) Providing a quiet and calm environment
Rationale: Clients with generalized anxiety disorder (GAD) benefit from
a calm and quiet environment to help reduce excessive worry and
anxiety. While medication (such as benzodiazepines) may be prescribed
in some cases, creating a tranquil space is a non-invasive and immediate
intervention.
2. A nurse is assessing a client who is suspected of having major
depressive disorder. Which of the following symptoms would the
nurse expect to find?
A) Increased energy levels B) Feelings of hopelessness C) Racing
thoughts D) Excessive talkativeness
Answer: B) Feelings of hopelessness
Rationale: One of the hallmark symptoms of major depressive disorder
is persistent feelings of hopelessness. The other options (increased
energy, racing thoughts, excessive talkativeness) are more commonly
seen in manic episodes associated with bipolar disorder.
3. A client diagnosed with schizophrenia is prescribed an antipsychotic
medication. Which of the following side effects is most important for
the nurse to monitor for in the first few weeks of therapy?
,A) Weight gain B) Muscle rigidity and tremors C) Sedation D)
Hyperglycemia
Answer: B) Muscle rigidity and tremors
Rationale: Antipsychotic medications, especially first-generation
(typical) antipsychotics, can cause extrapyramidal symptoms (EPS) like
muscle rigidity and tremors. Monitoring for EPS is crucial, especially
during the initial stages of therapy.
4. A nurse is caring for a client with borderline personality disorder
(BPD). Which of the following behaviors should the nurse be aware
of?
A) Lack of empathy for others B) Fear of abandonment C) Social
withdrawal and isolation D) Grandiose sense of self-importance
Answer: B) Fear of abandonment
Rationale: Individuals with borderline personality disorder often
experience intense fear of abandonment, which can lead to frantic
efforts to avoid being abandoned. This is a core feature of BPD, whereas
the other options are more characteristic of narcissistic personality
disorder.
5. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following strategies is most effective for
managing flashbacks?
A) Encouraging the client to recall the traumatic event in detail B) Using
grounding techniques to focus the client on the present moment C)
Providing a quiet environment with no interaction D) Asking the client
to avoid reminders of the trauma
, Answer: B) Using grounding techniques to focus the client on the
present moment
Rationale: Grounding techniques help clients with PTSD detach from
distressing flashbacks and focus on the present moment. Encouraging
clients to avoid or recall the trauma is not effective in managing
flashbacks and may increase distress.
6. A nurse is caring for a client who is taking lithium for bipolar
disorder. Which of the following statements by the client indicates the
need for further education about the medication?
A) "I will drink plenty of fluids, especially water." B) "I need to get my
thyroid checked regularly." C) "I should avoid high-salt foods in my diet."
D) "I will avoid taking ibuprofen while on this medication."
Answer: C) "I should avoid high-salt foods in my diet."
Rationale: Clients on lithium should maintain a normal salt intake, as
changes in sodium levels can affect lithium levels. Avoiding high-salt
foods is not necessary. The other statements are appropriate as clients
on lithium need regular thyroid monitoring, hydration, and avoidance of
NSAIDs like ibuprofen.
7. A nurse is caring for a client with obsessive-compulsive disorder
(OCD). Which intervention would be most appropriate to help manage
the client's compulsions?
A) Encourage the client to stop performing compulsions immediately B)
Limit the time the client spends performing compulsions C) Praise the
client for performing compulsions correctly D) Allow the client to
engage in compulsive behaviors without interruption
(GAD). Which of the following is the most appropriate intervention to
reduce anxiety in the client?
A) Encouraging the client to confront their fear B) Administering a
benzodiazepine as prescribed C) Encouraging the client to avoid
stressful situations D) Providing a quiet and calm environment
Answer: D) Providing a quiet and calm environment
Rationale: Clients with generalized anxiety disorder (GAD) benefit from
a calm and quiet environment to help reduce excessive worry and
anxiety. While medication (such as benzodiazepines) may be prescribed
in some cases, creating a tranquil space is a non-invasive and immediate
intervention.
2. A nurse is assessing a client who is suspected of having major
depressive disorder. Which of the following symptoms would the
nurse expect to find?
A) Increased energy levels B) Feelings of hopelessness C) Racing
thoughts D) Excessive talkativeness
Answer: B) Feelings of hopelessness
Rationale: One of the hallmark symptoms of major depressive disorder
is persistent feelings of hopelessness. The other options (increased
energy, racing thoughts, excessive talkativeness) are more commonly
seen in manic episodes associated with bipolar disorder.
3. A client diagnosed with schizophrenia is prescribed an antipsychotic
medication. Which of the following side effects is most important for
the nurse to monitor for in the first few weeks of therapy?
,A) Weight gain B) Muscle rigidity and tremors C) Sedation D)
Hyperglycemia
Answer: B) Muscle rigidity and tremors
Rationale: Antipsychotic medications, especially first-generation
(typical) antipsychotics, can cause extrapyramidal symptoms (EPS) like
muscle rigidity and tremors. Monitoring for EPS is crucial, especially
during the initial stages of therapy.
4. A nurse is caring for a client with borderline personality disorder
(BPD). Which of the following behaviors should the nurse be aware
of?
A) Lack of empathy for others B) Fear of abandonment C) Social
withdrawal and isolation D) Grandiose sense of self-importance
Answer: B) Fear of abandonment
Rationale: Individuals with borderline personality disorder often
experience intense fear of abandonment, which can lead to frantic
efforts to avoid being abandoned. This is a core feature of BPD, whereas
the other options are more characteristic of narcissistic personality
disorder.
5. A nurse is caring for a client with post-traumatic stress disorder
(PTSD). Which of the following strategies is most effective for
managing flashbacks?
A) Encouraging the client to recall the traumatic event in detail B) Using
grounding techniques to focus the client on the present moment C)
Providing a quiet environment with no interaction D) Asking the client
to avoid reminders of the trauma
, Answer: B) Using grounding techniques to focus the client on the
present moment
Rationale: Grounding techniques help clients with PTSD detach from
distressing flashbacks and focus on the present moment. Encouraging
clients to avoid or recall the trauma is not effective in managing
flashbacks and may increase distress.
6. A nurse is caring for a client who is taking lithium for bipolar
disorder. Which of the following statements by the client indicates the
need for further education about the medication?
A) "I will drink plenty of fluids, especially water." B) "I need to get my
thyroid checked regularly." C) "I should avoid high-salt foods in my diet."
D) "I will avoid taking ibuprofen while on this medication."
Answer: C) "I should avoid high-salt foods in my diet."
Rationale: Clients on lithium should maintain a normal salt intake, as
changes in sodium levels can affect lithium levels. Avoiding high-salt
foods is not necessary. The other statements are appropriate as clients
on lithium need regular thyroid monitoring, hydration, and avoidance of
NSAIDs like ibuprofen.
7. A nurse is caring for a client with obsessive-compulsive disorder
(OCD). Which intervention would be most appropriate to help manage
the client's compulsions?
A) Encourage the client to stop performing compulsions immediately B)
Limit the time the client spends performing compulsions C) Praise the
client for performing compulsions correctly D) Allow the client to
engage in compulsive behaviors without interruption
