and Answers | Latest Version |
2025/2026 | Correct & Verified
A client with schizophrenia states, “I hear a voice telling me to hurt myself.” What is the nurse’s
priority action?
✔✔Ensure the client’s immediate safety and notify the healthcare provider.
A client with major depression has stopped eating. What is the nurse’s most important
intervention?
✔✔Monitor nutritional intake and encourage small, frequent, high-calorie meals.
A client with bipolar disorder is pacing rapidly, talking loudly, and unable to sit. What phase is
the client experiencing?
✔✔Manic episode.
A client experiencing alcohol withdrawal becomes agitated and reports visual hallucinations.
What is the nurse’s priority?
✔✔Monitor for seizures and administer prescribed benzodiazepines.
1
,A client taking lithium reports diarrhea and tremors. What should the nurse suspect?
✔✔Lithium toxicity.
A client states, “I can’t sleep because I keep thinking about the same things over and over.” What
disorder does this describe?
✔✔Obsessive-compulsive disorder.
A client with PTSD avoids certain places because they trigger memories of trauma. What type of
symptom is this?
✔✔Avoidance.
A client with schizophrenia is unable to connect thoughts logically and their speech is hard to
follow. What is this called?
✔✔Loose associations.
A client with depression says, “I don’t have any reason to live anymore.” What is the nurse’s first
action?
✔✔Conduct a suicide risk assessment.
2
,A client with schizophrenia suddenly imitates every movement the nurse makes. What is this
behavior?
✔✔Echopraxia.
A client with borderline personality disorder makes extreme statements like, “You’re the only
one I trust,” then later says, “You’re the worst nurse here.” What is this behavior?
✔✔Splitting.
A client who abuses alcohol shows memory loss and confusion. What condition should the nurse
suspect?
✔✔Wernicke-Korsakoff syndrome.
A client with mania is constantly active and unable to sit still long enough to eat meals. What
intervention is most appropriate?
✔✔Offer portable, high-calorie finger foods.
A client prescribed clozapine reports sore throat and fever. What should the nurse do first?
✔✔Check white blood cell count immediately.
3
, A client in a panic attack is trembling, hyperventilating, and unable to focus. What is the nurse’s
first action?
✔✔Stay with the client and use a calm, reassuring voice.
A client reports seeing spiders crawling on the wall, but none are present. What is this symptom?
✔✔Visual hallucination.
A client believes their thoughts are being broadcast on the radio. What is this symptom called?
✔✔Delusion of thought broadcasting.
A client with depression sits quietly and does not respond verbally. What type of affect is this?
✔✔Flat affect.
A client taking haloperidol develops muscle stiffness, high fever, and confusion. What condition
is suspected?
✔✔Neuroleptic malignant syndrome.
A client taking an MAOI asks about diet. What should the nurse emphasize?
4