1. A nurse is caring for a client diagnosed with schizophrenia. The
client expresses paranoia and states, "People are watching me
through the walls." What is the most appropriate response by the
nurse?
a) "Don't be silly, there's no one watching you."
b) "I understand that you feel that way, but I assure you, no one is
watching you."
c) "You are just having a bad day, and this will pass."
d) "You need to focus on getting better and stop thinking about these
things."
Answer: b) "I understand that you feel that way, but I assure you, no
one is watching you."
Rationale: The most therapeutic response is to acknowledge the client's
feelings without reinforcing the delusion. Offering reassurance and
validating their experience while clarifying the reality helps maintain
trust while not agreeing with the delusion.
2. A nurse is caring for a client who has been prescribed an
antidepressant. The client reports feeling restless and unable to sit
still. Which side effect should the nurse suspect?
a) Hypotension
b) Akathisia
c) Sedation
d) Weight gain
Answer: b) Akathisia
,Rationale: Akathisia is a common side effect of certain antidepressants,
especially selective serotonin reuptake inhibitors (SSRIs), and is
characterized by restlessness and an inability to sit still.
3. A nurse is working with a client who has obsessive-compulsive
disorder (OCD). Which of the following is an appropriate intervention
to reduce the client's anxiety related to compulsive behaviors?
a) Encourage the client to resist performing compulsive behaviors.
b) Allow the client to perform compulsive behaviors in a structured
manner.
c) Tell the client that their compulsive behaviors are irrational and
should stop.
d) Limit the client's access to activities that trigger their compulsions.
Answer: b) Allow the client to perform compulsive behaviors in a
structured manner.
Rationale: Allowing the client to perform compulsive behaviors in a
structured and controlled manner helps reduce anxiety and provides a
way to manage the symptoms while also gradually working to reduce
the frequency of compulsive behaviors through therapy.
4. A client with post-traumatic stress disorder (PTSD) is experiencing
flashbacks. What is the best action for the nurse to take?
a) Hold the client’s hand and reassure them that they are safe.
b) Encourage the client to talk about the traumatic event.
c) Tell the client to stop thinking about the flashbacks.
d) Remind the client that they are in a safe place and guide them back
to reality.
, Answer: d) Remind the client that they are in a safe place and guide
them back to reality.
Rationale: When a client experiences flashbacks, it’s important to help
them regain a sense of safety by grounding them in the present.
Reorienting the client to reality and reminding them of their current
safe environment is crucial for managing PTSD symptoms.
5. A client diagnosed with borderline personality disorder is
demonstrating impulsive behaviors, such as self-harm and intense,
unstable relationships. Which of the following interventions is most
important?
a) Set clear and consistent boundaries.
b) Encourage the client to explore their past trauma.
c) Focus on improving the client's social skills.
d) Provide the client with information about medication options.
Answer: a) Set clear and consistent boundaries.
Rationale: Clients with borderline personality disorder benefit from
clear and consistent boundaries, which help provide structure and
reduce impulsive behaviors. Boundaries also promote a sense of safety
and consistency, which are often lacking in these clients' lives.
6. A nurse is caring for a client who has recently been started on
lithium therapy. Which of the following should the nurse include in
the client's teaching plan?
a) "You should increase your fluid intake to avoid dehydration."
b) "You should limit your salt intake to prevent lithium toxicity."
c) "You should stop the medication if you develop any hand tremors."
client expresses paranoia and states, "People are watching me
through the walls." What is the most appropriate response by the
nurse?
a) "Don't be silly, there's no one watching you."
b) "I understand that you feel that way, but I assure you, no one is
watching you."
c) "You are just having a bad day, and this will pass."
d) "You need to focus on getting better and stop thinking about these
things."
Answer: b) "I understand that you feel that way, but I assure you, no
one is watching you."
Rationale: The most therapeutic response is to acknowledge the client's
feelings without reinforcing the delusion. Offering reassurance and
validating their experience while clarifying the reality helps maintain
trust while not agreeing with the delusion.
2. A nurse is caring for a client who has been prescribed an
antidepressant. The client reports feeling restless and unable to sit
still. Which side effect should the nurse suspect?
a) Hypotension
b) Akathisia
c) Sedation
d) Weight gain
Answer: b) Akathisia
,Rationale: Akathisia is a common side effect of certain antidepressants,
especially selective serotonin reuptake inhibitors (SSRIs), and is
characterized by restlessness and an inability to sit still.
3. A nurse is working with a client who has obsessive-compulsive
disorder (OCD). Which of the following is an appropriate intervention
to reduce the client's anxiety related to compulsive behaviors?
a) Encourage the client to resist performing compulsive behaviors.
b) Allow the client to perform compulsive behaviors in a structured
manner.
c) Tell the client that their compulsive behaviors are irrational and
should stop.
d) Limit the client's access to activities that trigger their compulsions.
Answer: b) Allow the client to perform compulsive behaviors in a
structured manner.
Rationale: Allowing the client to perform compulsive behaviors in a
structured and controlled manner helps reduce anxiety and provides a
way to manage the symptoms while also gradually working to reduce
the frequency of compulsive behaviors through therapy.
4. A client with post-traumatic stress disorder (PTSD) is experiencing
flashbacks. What is the best action for the nurse to take?
a) Hold the client’s hand and reassure them that they are safe.
b) Encourage the client to talk about the traumatic event.
c) Tell the client to stop thinking about the flashbacks.
d) Remind the client that they are in a safe place and guide them back
to reality.
, Answer: d) Remind the client that they are in a safe place and guide
them back to reality.
Rationale: When a client experiences flashbacks, it’s important to help
them regain a sense of safety by grounding them in the present.
Reorienting the client to reality and reminding them of their current
safe environment is crucial for managing PTSD symptoms.
5. A client diagnosed with borderline personality disorder is
demonstrating impulsive behaviors, such as self-harm and intense,
unstable relationships. Which of the following interventions is most
important?
a) Set clear and consistent boundaries.
b) Encourage the client to explore their past trauma.
c) Focus on improving the client's social skills.
d) Provide the client with information about medication options.
Answer: a) Set clear and consistent boundaries.
Rationale: Clients with borderline personality disorder benefit from
clear and consistent boundaries, which help provide structure and
reduce impulsive behaviors. Boundaries also promote a sense of safety
and consistency, which are often lacking in these clients' lives.
6. A nurse is caring for a client who has recently been started on
lithium therapy. Which of the following should the nurse include in
the client's teaching plan?
a) "You should increase your fluid intake to avoid dehydration."
b) "You should limit your salt intake to prevent lithium toxicity."
c) "You should stop the medication if you develop any hand tremors."
