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1. A client with schizophrenia reports hearing voices that are
telling him to harm himself. What is the nurse's priority
intervention?
A. Ask the client to ignore the voices
B. Administer antipsychotic medication immediately
C. Ensure the client’s safety and initiate suicide precautions
D. Encourage the client to write down what the voices are
saying
Answer: C
Rationale: Safety is always the priority. Clients experiencing
command hallucinations that encourage self-harm require
immediate protective interventions.
2. A client is experiencing acute mania. Which nursing
intervention is most appropriate?
A. Encourage social interaction
B. Offer finger foods and high-calorie snacks
C. Require the client to participate in group therapy
D. Allow unlimited physical activity
,Answer: B
Rationale: Clients in mania may have little time or focus for meals;
finger foods and high-calorie snacks help maintain nutrition.
3. A client with major depressive disorder refuses to eat or drink.
What is the nurse's initial response?
A. Allow the client to fast
B. Encourage the client to eat with others
C. Assess for signs of dehydration or malnutrition
D. Document refusal and leave the room
Answer: C
Rationale: Physical assessment to identify risks of dehydration or
malnutrition is the priority for client safety.
4. A client with generalized anxiety disorder reports feeling tense
and restless. Which intervention should the nurse implement
first?
A. Teach deep breathing exercises
B. Encourage journaling
C. Schedule a weekly group session
D. Provide reading material on anxiety
Answer: A
Rationale: Immediate relief of physical tension through deep
breathing addresses the acute anxiety symptoms.
5. A client is receiving lithium therapy. Which laboratory result
indicates a therapeutic level?
A. 0.5 mEq/L
B. 1.0 mEq/L
C. 1.8 mEq/L
D. 2.5 mEq/L
,Answer: B
Rationale: The therapeutic range for lithium is 0.6–1.2 mEq/L; levels
above 1.5 mEq/L may indicate toxicity.
6. A client with borderline personality disorder becomes angry
and threatens staff. The nurse should:
A. Ignore the behavior
B. Respond in a calm, firm, and consistent manner
C. Immediately discharge the client
D. Argue with the client to prevent escalation
Answer: B
Rationale: A calm, consistent approach helps de-escalate potentially
dangerous behaviors without reinforcing them.
7. Which symptom is characteristic of post-traumatic stress
disorder (PTSD)?
A. Euphoria
B. Re-experiencing traumatic events
C. Delusions of grandeur
D. Social withdrawal only at work
Answer: B
Rationale: Recurrent, intrusive memories or flashbacks are hallmark
symptoms of PTSD.
8. A client with obsessive-compulsive disorder spends several
hours each day washing hands. What is the most therapeutic
approach?
A. Tell the client to stop immediately
B. Allow rituals but gradually reduce time spent
C. Punish the client for excessive handwashing
D. Ignore the behavior
, Answer: B
Rationale: Gradual exposure and response prevention helps reduce
compulsive behaviors while respecting the client’s anxiety level.
9. A client with anorexia nervosa is admitted to the hospital.
Which nursing diagnosis is priority?
A. Ineffective coping
B. Imbalanced nutrition: less than body requirements
C. Social isolation
D. Disturbed body image
Answer: B
Rationale: Addressing malnutrition is essential for physical
stabilization and safety.
10. A client receiving antipsychotic medication reports
stiffness, tremors, and drooling. The nurse suspects:
A. Serotonin syndrome
B. Neuroleptic malignant syndrome
C. Extrapyramidal side effects
D. Agranulocytosis
Answer: C
Rationale: Extrapyramidal symptoms (EPS) include tremor, rigidity,
bradykinesia, and drooling.
11. Which intervention is most appropriate for a client
experiencing hallucinations?
A. Confront the client about their hallucinations
B. Ask the client to describe the hallucinations
C. Ignore the client’s experiences
D. Reinforce reality gently and provide distraction