1. A nurse is assessing a client who is exhibiting signs of severe
anxiety. Which of the following symptoms would the nurse most likely
observe?
a) Excessive talking
b) Calm and relaxed posture
c) Pacing and restlessness
d) Slow, deliberate speech
Answer: c) Pacing and restlessness
Rationale: Severe anxiety often leads to physical manifestations, such as
pacing, restlessness, and an inability to remain still. This is a common
symptom of heightened physiological arousal in response to anxiety.
2. A client with depression states, "I have no reason to live." Which of
the following interventions should the nurse prioritize?
a) Encourage the client to take part in group activities.
b) Ask the client if they have a plan for suicide.
c) Tell the client that they have no reason to feel this way.
d) Suggest the client write in a journal about their feelings.
Answer: b) Ask the client if they have a plan for suicide.
Rationale: The nurse must assess for suicidal ideation, as statements
such as "I have no reason to live" may indicate suicidal thoughts. It is
essential to prioritize safety and intervene accordingly to prevent harm.
3. A client with bipolar disorder is experiencing mania. Which of the
following behaviors would the nurse most likely observe?
,a) Sleeping for extended periods
b) Speaking rapidly and impulsively
c) Withdrawing from social interactions
d) Demonstrating a slow, deliberate movement
Answer: b) Speaking rapidly and impulsively
Rationale: During mania, individuals may demonstrate impulsive
behavior and rapid speech due to the elevated mood, energy levels, and
decreased need for sleep, which are common characteristics of manic
episodes.
4. A nurse is planning care for a client with schizophrenia. Which of
the following would be the priority goal?
a) Enhance the client's social skills.
b) Decrease the frequency of delusions.
c) Maintain client safety.
d) Improve the client's nutritional status.
Answer: c) Maintain client safety.
Rationale: In schizophrenia, the priority goal is always client safety.
Delusions, hallucinations, and impaired judgment can increase the risk
of self-harm or harm to others, requiring priority attention to safety.
5. A client diagnosed with obsessive-compulsive disorder (OCD) is
repeatedly washing their hands. Which of the following interventions
is most appropriate for the nurse to implement?
a) Ignore the behavior and avoid acknowledging it.
b) Provide the client with positive reinforcement when they reduce the
frequency of hand washing.
, c) Discourage the client from washing their hands at all.
d) Redirect the client to engage in other activities, such as reading.
Answer: b) Provide the client with positive reinforcement when they
reduce the frequency of hand washing.
Rationale: Gradual reduction in compulsive behaviors should be
encouraged, and positive reinforcement can support the client in
decreasing the frequency of hand-washing rituals.
6. A nurse is conducting an assessment of a client with a history of
alcohol use disorder. Which of the following assessment findings
would be most concerning?
a) Tremors in the hands
b) Weight gain
c) Increased appetite
d) Slurred speech
Answer: a) Tremors in the hands
Rationale: Tremors, especially in the hands, can be a sign of alcohol
withdrawal, which can be life-threatening. Early detection and
intervention are crucial to prevent complications like seizures or
delirium tremens.
7. A nurse is caring for a client who is newly diagnosed with post-
traumatic stress disorder (PTSD). Which of the following is a common
characteristic of PTSD?
a) Avoidance of reminders of the traumatic event
b) Heightened energy and activity levels
anxiety. Which of the following symptoms would the nurse most likely
observe?
a) Excessive talking
b) Calm and relaxed posture
c) Pacing and restlessness
d) Slow, deliberate speech
Answer: c) Pacing and restlessness
Rationale: Severe anxiety often leads to physical manifestations, such as
pacing, restlessness, and an inability to remain still. This is a common
symptom of heightened physiological arousal in response to anxiety.
2. A client with depression states, "I have no reason to live." Which of
the following interventions should the nurse prioritize?
a) Encourage the client to take part in group activities.
b) Ask the client if they have a plan for suicide.
c) Tell the client that they have no reason to feel this way.
d) Suggest the client write in a journal about their feelings.
Answer: b) Ask the client if they have a plan for suicide.
Rationale: The nurse must assess for suicidal ideation, as statements
such as "I have no reason to live" may indicate suicidal thoughts. It is
essential to prioritize safety and intervene accordingly to prevent harm.
3. A client with bipolar disorder is experiencing mania. Which of the
following behaviors would the nurse most likely observe?
,a) Sleeping for extended periods
b) Speaking rapidly and impulsively
c) Withdrawing from social interactions
d) Demonstrating a slow, deliberate movement
Answer: b) Speaking rapidly and impulsively
Rationale: During mania, individuals may demonstrate impulsive
behavior and rapid speech due to the elevated mood, energy levels, and
decreased need for sleep, which are common characteristics of manic
episodes.
4. A nurse is planning care for a client with schizophrenia. Which of
the following would be the priority goal?
a) Enhance the client's social skills.
b) Decrease the frequency of delusions.
c) Maintain client safety.
d) Improve the client's nutritional status.
Answer: c) Maintain client safety.
Rationale: In schizophrenia, the priority goal is always client safety.
Delusions, hallucinations, and impaired judgment can increase the risk
of self-harm or harm to others, requiring priority attention to safety.
5. A client diagnosed with obsessive-compulsive disorder (OCD) is
repeatedly washing their hands. Which of the following interventions
is most appropriate for the nurse to implement?
a) Ignore the behavior and avoid acknowledging it.
b) Provide the client with positive reinforcement when they reduce the
frequency of hand washing.
, c) Discourage the client from washing their hands at all.
d) Redirect the client to engage in other activities, such as reading.
Answer: b) Provide the client with positive reinforcement when they
reduce the frequency of hand washing.
Rationale: Gradual reduction in compulsive behaviors should be
encouraged, and positive reinforcement can support the client in
decreasing the frequency of hand-washing rituals.
6. A nurse is conducting an assessment of a client with a history of
alcohol use disorder. Which of the following assessment findings
would be most concerning?
a) Tremors in the hands
b) Weight gain
c) Increased appetite
d) Slurred speech
Answer: a) Tremors in the hands
Rationale: Tremors, especially in the hands, can be a sign of alcohol
withdrawal, which can be life-threatening. Early detection and
intervention are crucial to prevent complications like seizures or
delirium tremens.
7. A nurse is caring for a client who is newly diagnosed with post-
traumatic stress disorder (PTSD). Which of the following is a common
characteristic of PTSD?
a) Avoidance of reminders of the traumatic event
b) Heightened energy and activity levels
