| Complete A+ Guide with Proven Solutions for Top Scores!
By Delight
,1. A nurse is caring for a client with schizophrenia who is experiencing
auditory hallucinations. What is the best initial response?
Options:
• A. What are the voices telling you?
• B. You should not listen to those voices.
• C. Are you hearing voices again?
• D. I do not hear any voices.
Correct Answer: A
Rationale: The priority is safety; asking about the content of the hallucination
helps assess potential risk.
2. A client with major depressive disorder refuses to get out of bed, eat, or
attend therapy. What is the priority nursing intervention?
Options:
• A. Respect their right to refuse care.
• B. Provide a calm, structured environment and encourage participation.
• C. Ask the physician to order restraints.
• D. Tell the client that their behavior is inappropriate.
,Correct Answer: B
Rationale: Depression often causes withdrawal; therapeutic encouragement is
appropriate.
3. A client with post-traumatic stress disorder (PTSD) is experiencing
hypervigilance and irritability. Which intervention is most appropriate?
Options:
• A. Provide a quiet, low-stimulation environment.
• B. Encourage the client to confront traumatic memories.
• C. Involve the client in group therapy immediately.
• D. Tell the client to avoid discussing the trauma.
Correct Answer: A
Rationale: A calm, low-stimulation environment helps reduce symptoms of
hypervigilance in PTSD.
4. A client is prescribed an SSRI (Selective Serotonin Reuptake Inhibitor)
for depression. Which side effect should the nurse monitor for?
Options:
• A. Tardive dyskinesia
, • B. Serotonin syndrome
• C. Hypertension
• D. Weight loss
Correct Answer: B
Rationale: Serotonin syndrome is a potentially life-threatening side effect of
SSRIs. Symptoms include confusion, agitation, and hyperreflexia.
5. What is the most common type of hallucination in schizophrenia?
Options:
• A. Visual
• B. Auditory
• C. Olfactory
• D. Tactile
Correct Answer: B
Rationale: Auditory hallucinations are the most common type in individuals
with schizophrenia.