Answers | Latest Version | 2025/2026 |
Correct & Verified
A client states, “I feel like giving up, nothing will ever change.” What is the nurse’s priority
action?
✔✔Assess the client for suicidal ideation.
A client with schizophrenia refuses to attend group therapy because “the others are plotting
against me.” What symptom is this?
✔✔Paranoid delusion.
A client taking lithium reports blurred vision and severe diarrhea. What should the nurse suspect?
✔✔Lithium toxicity.
A client experiencing alcohol withdrawal suddenly becomes disoriented and agitated. What is the
nurse’s immediate concern?
✔✔Risk for seizures and delirium tremens.
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,A client with OCD spends several hours organizing clothes by color. What is the best nursing
intervention?
✔✔Allow the behavior within limits while working on anxiety reduction strategies.
A client diagnosed with PTSD has recurring flashbacks. What is the nurse’s priority
intervention?
✔✔Help the client use grounding techniques to stay oriented to the present.
A client with major depression isolates in the room and avoids interaction. What should the nurse
do?
✔✔Offer brief, frequent interactions without pressure to respond.
A client with schizophrenia reports hearing voices commanding self-harm. What is the nurse’s
priority?
✔✔Ensure the client’s safety by assessing and implementing precautions.
A client being treated with haloperidol develops muscle stiffness, fever, and altered mental
status. What condition should the nurse suspect?
✔✔Neuroleptic malignant syndrome.
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, A client with bipolar disorder is unable to sit still and speaks rapidly. What phase of illness is
this?
✔✔Manic episode.
A client suddenly shouts unrelated words and rhymes during conversation. What is this speech
pattern called?
✔✔Clang associations.
A client with dementia is found wandering outside the facility. What is the priority nursing
action?
✔✔Return the client safely and implement measures to prevent further wandering.
A client states, “The television is sending me personal messages.” What is this symptom called?
✔✔Delusion of reference.
A client taking clozapine develops sudden sore throat and fever. What is the nurse’s best action?
✔✔Notify the provider and obtain a white blood cell count.
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