1. A client with schizophrenia is exhibiting symptoms of delusions and
auditory hallucinations. The nurse should provide which of the
following interventions to address these symptoms?
A. Encourage the client to express their feelings of paranoia
B. Use distraction techniques to divert the client’s attention from the
hallucinations
C. Tell the client that their hallucinations are not real
D. Provide an environment with minimal stimuli
Answer: B. Use distraction techniques to divert the client’s attention
from the hallucinations
Rationale: Distraction techniques can help divert the client’s attention
away from hallucinations and delusions. Telling the client that their
hallucinations are not real (C) may cause confusion and mistrust.
Encouraging them to express paranoia (A) could reinforce their
delusions, and an overly quiet environment (D) might increase their
sense of isolation or contribute to further hallucinations.
2. Which of the following is the most effective way for a nurse to
support a client who has a history of severe depression and is
experiencing suicidal ideation?
A. Encourage the client to keep a journal of their feelings
B. Remain with the client at all times when they express suicidal
thoughts
C. Provide the client with a list of coping strategies
D. Tell the client to snap out of their depression
Answer: B. Remain with the client at all times when they express
suicidal thoughts
,Rationale: The priority intervention for a client with suicidal ideation is
to ensure their safety. Remaining with the client helps prevent self-
harm. While journaling (A) and coping strategies (C) can be helpful, they
are not the immediate priorities when there is a risk of suicide. Telling a
client to “snap out of it” (D) minimizes the severity of their condition
and is not therapeutic.
3. A nurse is caring for a client who is diagnosed with obsessive-
compulsive disorder (OCD). Which of the following interventions is
most appropriate to help the client manage compulsive behaviors?
A. Allow the client to perform rituals, but set time limits for them
B. Discourage the client from performing rituals to reduce anxiety
C. Tell the client that they are not allowed to perform any rituals
D. Ignore the client’s compulsions and focus on building rapport
Answer: A. Allow the client to perform rituals, but set time limits for
them
Rationale: Allowing the client to perform rituals while gradually setting
limits helps reduce anxiety in a controlled way. Completely discouraging
rituals (B) may increase anxiety, while telling the client they cannot
perform rituals (C) could exacerbate the compulsions. Ignoring
compulsions (D) does not address the client’s needs or help with
management.
4. A client is diagnosed with post-traumatic stress disorder (PTSD).
Which of the following interventions should the nurse implement to
help the client process traumatic memories?
,A. Encourage the client to avoid talking about the traumatic event
B. Encourage the client to share their experience at their own pace
C. Instruct the client to immediately confront traumatic memories
D. Provide the client with medications to block memories
Answer: B. Encourage the client to share their experience at their own
pace
Rationale: Allowing the client to share their experience at their own
pace is important in trauma-focused therapy. Encouraging avoidance (A)
can worsen PTSD symptoms, while immediately confronting memories
(C) may be too overwhelming for the client. Blocking memories with
medication (D) is not an effective or therapeutic approach.
5. A client with bipolar disorder is in a manic phase. The nurse
observes that the client is speaking rapidly and has grandiose ideas.
Which of the following is the most appropriate nursing action?
A. Provide the client with detailed explanations of their behavior
B. Allow the client to talk without interruption to express their ideas
C. Set clear limits on inappropriate behaviors and redirect the
conversation
D. Encourage the client to rest and take a nap
Answer: C. Set clear limits on inappropriate behaviors and redirect the
conversation
Rationale: During a manic phase, clients may have pressured speech
and unrealistic beliefs. Setting limits and redirecting the conversation
helps manage their behavior. Allowing the client to speak without limits
(B) or rest (D) may reinforce the manic behavior. Detailed explanations
(A) may be ineffective as the client may not be receptive in this state.
, 6. A nurse is teaching a client with generalized anxiety disorder (GAD)
about relaxation techniques. Which of the following statements by the
client indicates a need for further teaching?
A. “I will practice deep breathing exercises when I feel anxious.”
B. “I will use muscle relaxation techniques to reduce tension.”
C. “I will avoid stressful situations to prevent anxiety.”
D. “I will use these techniques every day, even when I don’t feel
anxious.”
Answer: C. “I will avoid stressful situations to prevent anxiety.”
Rationale: While avoiding stress may seem helpful, it is unrealistic and
unhelpful in managing GAD. The goal of therapy is to help clients cope
with anxiety rather than avoid it. Statements A, B, and D indicate a
correct understanding of relaxation techniques, which should be
practiced regularly.
7. Which of the following actions should the nurse take when working
with a client who has a borderline personality disorder (BPD) and is
demonstrating impulsive behaviors?
A. Ignore the impulsive behaviors and focus on positive behaviors
B. Set clear and consistent boundaries while maintaining a therapeutic
relationship
C. Avoid confrontation and allow the client to make decisions without
guidance
D. Discuss the client’s impulsive behaviors in group therapy only
Answer: B. Set clear and consistent boundaries while maintaining a
therapeutic relationship
auditory hallucinations. The nurse should provide which of the
following interventions to address these symptoms?
A. Encourage the client to express their feelings of paranoia
B. Use distraction techniques to divert the client’s attention from the
hallucinations
C. Tell the client that their hallucinations are not real
D. Provide an environment with minimal stimuli
Answer: B. Use distraction techniques to divert the client’s attention
from the hallucinations
Rationale: Distraction techniques can help divert the client’s attention
away from hallucinations and delusions. Telling the client that their
hallucinations are not real (C) may cause confusion and mistrust.
Encouraging them to express paranoia (A) could reinforce their
delusions, and an overly quiet environment (D) might increase their
sense of isolation or contribute to further hallucinations.
2. Which of the following is the most effective way for a nurse to
support a client who has a history of severe depression and is
experiencing suicidal ideation?
A. Encourage the client to keep a journal of their feelings
B. Remain with the client at all times when they express suicidal
thoughts
C. Provide the client with a list of coping strategies
D. Tell the client to snap out of their depression
Answer: B. Remain with the client at all times when they express
suicidal thoughts
,Rationale: The priority intervention for a client with suicidal ideation is
to ensure their safety. Remaining with the client helps prevent self-
harm. While journaling (A) and coping strategies (C) can be helpful, they
are not the immediate priorities when there is a risk of suicide. Telling a
client to “snap out of it” (D) minimizes the severity of their condition
and is not therapeutic.
3. A nurse is caring for a client who is diagnosed with obsessive-
compulsive disorder (OCD). Which of the following interventions is
most appropriate to help the client manage compulsive behaviors?
A. Allow the client to perform rituals, but set time limits for them
B. Discourage the client from performing rituals to reduce anxiety
C. Tell the client that they are not allowed to perform any rituals
D. Ignore the client’s compulsions and focus on building rapport
Answer: A. Allow the client to perform rituals, but set time limits for
them
Rationale: Allowing the client to perform rituals while gradually setting
limits helps reduce anxiety in a controlled way. Completely discouraging
rituals (B) may increase anxiety, while telling the client they cannot
perform rituals (C) could exacerbate the compulsions. Ignoring
compulsions (D) does not address the client’s needs or help with
management.
4. A client is diagnosed with post-traumatic stress disorder (PTSD).
Which of the following interventions should the nurse implement to
help the client process traumatic memories?
,A. Encourage the client to avoid talking about the traumatic event
B. Encourage the client to share their experience at their own pace
C. Instruct the client to immediately confront traumatic memories
D. Provide the client with medications to block memories
Answer: B. Encourage the client to share their experience at their own
pace
Rationale: Allowing the client to share their experience at their own
pace is important in trauma-focused therapy. Encouraging avoidance (A)
can worsen PTSD symptoms, while immediately confronting memories
(C) may be too overwhelming for the client. Blocking memories with
medication (D) is not an effective or therapeutic approach.
5. A client with bipolar disorder is in a manic phase. The nurse
observes that the client is speaking rapidly and has grandiose ideas.
Which of the following is the most appropriate nursing action?
A. Provide the client with detailed explanations of their behavior
B. Allow the client to talk without interruption to express their ideas
C. Set clear limits on inappropriate behaviors and redirect the
conversation
D. Encourage the client to rest and take a nap
Answer: C. Set clear limits on inappropriate behaviors and redirect the
conversation
Rationale: During a manic phase, clients may have pressured speech
and unrealistic beliefs. Setting limits and redirecting the conversation
helps manage their behavior. Allowing the client to speak without limits
(B) or rest (D) may reinforce the manic behavior. Detailed explanations
(A) may be ineffective as the client may not be receptive in this state.
, 6. A nurse is teaching a client with generalized anxiety disorder (GAD)
about relaxation techniques. Which of the following statements by the
client indicates a need for further teaching?
A. “I will practice deep breathing exercises when I feel anxious.”
B. “I will use muscle relaxation techniques to reduce tension.”
C. “I will avoid stressful situations to prevent anxiety.”
D. “I will use these techniques every day, even when I don’t feel
anxious.”
Answer: C. “I will avoid stressful situations to prevent anxiety.”
Rationale: While avoiding stress may seem helpful, it is unrealistic and
unhelpful in managing GAD. The goal of therapy is to help clients cope
with anxiety rather than avoid it. Statements A, B, and D indicate a
correct understanding of relaxation techniques, which should be
practiced regularly.
7. Which of the following actions should the nurse take when working
with a client who has a borderline personality disorder (BPD) and is
demonstrating impulsive behaviors?
A. Ignore the impulsive behaviors and focus on positive behaviors
B. Set clear and consistent boundaries while maintaining a therapeutic
relationship
C. Avoid confrontation and allow the client to make decisions without
guidance
D. Discuss the client’s impulsive behaviors in group therapy only
Answer: B. Set clear and consistent boundaries while maintaining a
therapeutic relationship
