1. A nurse is caring for a client with major depressive disorder who has
been prescribed fluoxetine. The nurse should monitor for which of the
following adverse effects during the initial weeks of therapy?
A) Increased energy
B) Insomnia
C) Nausea
D) Weight gain
Answer: C) Nausea
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI)
that can cause gastrointestinal upset, particularly nausea, during the
initial stages of treatment. This side effect typically decreases after the
first few weeks. The other options (increased energy, insomnia, and
weight gain) may occur later or be related to other medications or
conditions.
2. A client with schizophrenia tells the nurse, "The voices are telling
me to hurt myself." Which of the following is the most appropriate
nursing intervention?
A) Ask the client to describe the voices in detail
B) Provide a calm and nonjudgmental environment
C) Reinforce that the voices are not real
D) Encourage the client to ignore the voices
Answer: B) Provide a calm and nonjudgmental environment
Rationale: Creating a calm, safe, and supportive environment is
essential for clients with schizophrenia, especially if they are
experiencing auditory hallucinations. Asking the client to describe the
voices or reinforcing that the voices are not real may not be helpful or
,effective in this acute phase. Encouraging the client to ignore the voices
could increase anxiety and lead to further distress.
3. A nurse is caring for a client with post-traumatic stress disorder
(PTSD) who is experiencing a flashback. Which of the following actions
is most appropriate?
A) Ask the client to describe the flashback in detail
B) Gently redirect the client to the present environment
C) Tell the client to snap out of the flashback
D) Encourage the client to confront the trauma directly
Answer: B) Gently redirect the client to the present environment
Rationale: During a flashback, the client may feel as if they are reliving a
traumatic event. Gently redirecting the client to the present moment
(e.g., by grounding them with sensory cues like touch or deep
breathing) helps reduce the emotional intensity. Asking the client to
describe the flashback or confronting the trauma directly may be
overwhelming for the client.
4. A nurse is caring for a client with bipolar disorder. The client is in
the manic phase and is displaying impulsive behavior. Which of the
following interventions is most appropriate?
A) Allow the client to make their own decisions regarding safety
B) Provide a quiet environment and limit stimulation
C) Encourage the client to take part in a group activity
D) Offer choices for their daily activities to promote autonomy
Answer: B) Provide a quiet environment and limit stimulation
, Rationale: During the manic phase of bipolar disorder, clients may
experience heightened energy, impulsivity, and agitation. A calm,
structured, and quiet environment helps reduce overstimulation and
potential harm. While promoting autonomy is important, the priority in
the manic phase is managing impulsive and risky behaviors. Limiting
stimulation can prevent escalation.
5. A nurse is assessing a client with an anxiety disorder. Which of the
following physical symptoms is most commonly associated with
anxiety?
A) Bradycardia
B) Diaphoresis
C) Constipation
D) Weight gain
Answer: B) Diaphoresis
Rationale: Diaphoresis (excessive sweating) is a common physical
symptom of anxiety, along with other symptoms such as tachycardia,
tremors, and shortness of breath. Bradycardia, constipation, and weight
gain are typically not associated with anxiety but may be related to
other health conditions or medications.
6. A nurse is teaching a client with generalized anxiety disorder about
relaxation techniques. Which of the following techniques should the
nurse recommend to help manage anxiety?
A) Progressive muscle relaxation
B) Hyperventilation exercises
been prescribed fluoxetine. The nurse should monitor for which of the
following adverse effects during the initial weeks of therapy?
A) Increased energy
B) Insomnia
C) Nausea
D) Weight gain
Answer: C) Nausea
Rationale: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI)
that can cause gastrointestinal upset, particularly nausea, during the
initial stages of treatment. This side effect typically decreases after the
first few weeks. The other options (increased energy, insomnia, and
weight gain) may occur later or be related to other medications or
conditions.
2. A client with schizophrenia tells the nurse, "The voices are telling
me to hurt myself." Which of the following is the most appropriate
nursing intervention?
A) Ask the client to describe the voices in detail
B) Provide a calm and nonjudgmental environment
C) Reinforce that the voices are not real
D) Encourage the client to ignore the voices
Answer: B) Provide a calm and nonjudgmental environment
Rationale: Creating a calm, safe, and supportive environment is
essential for clients with schizophrenia, especially if they are
experiencing auditory hallucinations. Asking the client to describe the
voices or reinforcing that the voices are not real may not be helpful or
,effective in this acute phase. Encouraging the client to ignore the voices
could increase anxiety and lead to further distress.
3. A nurse is caring for a client with post-traumatic stress disorder
(PTSD) who is experiencing a flashback. Which of the following actions
is most appropriate?
A) Ask the client to describe the flashback in detail
B) Gently redirect the client to the present environment
C) Tell the client to snap out of the flashback
D) Encourage the client to confront the trauma directly
Answer: B) Gently redirect the client to the present environment
Rationale: During a flashback, the client may feel as if they are reliving a
traumatic event. Gently redirecting the client to the present moment
(e.g., by grounding them with sensory cues like touch or deep
breathing) helps reduce the emotional intensity. Asking the client to
describe the flashback or confronting the trauma directly may be
overwhelming for the client.
4. A nurse is caring for a client with bipolar disorder. The client is in
the manic phase and is displaying impulsive behavior. Which of the
following interventions is most appropriate?
A) Allow the client to make their own decisions regarding safety
B) Provide a quiet environment and limit stimulation
C) Encourage the client to take part in a group activity
D) Offer choices for their daily activities to promote autonomy
Answer: B) Provide a quiet environment and limit stimulation
, Rationale: During the manic phase of bipolar disorder, clients may
experience heightened energy, impulsivity, and agitation. A calm,
structured, and quiet environment helps reduce overstimulation and
potential harm. While promoting autonomy is important, the priority in
the manic phase is managing impulsive and risky behaviors. Limiting
stimulation can prevent escalation.
5. A nurse is assessing a client with an anxiety disorder. Which of the
following physical symptoms is most commonly associated with
anxiety?
A) Bradycardia
B) Diaphoresis
C) Constipation
D) Weight gain
Answer: B) Diaphoresis
Rationale: Diaphoresis (excessive sweating) is a common physical
symptom of anxiety, along with other symptoms such as tachycardia,
tremors, and shortness of breath. Bradycardia, constipation, and weight
gain are typically not associated with anxiety but may be related to
other health conditions or medications.
6. A nurse is teaching a client with generalized anxiety disorder about
relaxation techniques. Which of the following techniques should the
nurse recommend to help manage anxiety?
A) Progressive muscle relaxation
B) Hyperventilation exercises
