1. A nurse is caring for a client diagnosed with schizophrenia. The
client is experiencing auditory hallucinations. Which of the
following should the nurse do first?
a) Encourage the client to describe the voices.
b) Ignore the hallucinations and continue with the care plan.
c) Offer the client a medication to calm down.
d) Ask the client to focus on reality-based activities.
Answer: a) Encourage the client to describe the voices.
Rationale: Encouraging the client to talk about the hallucinations helps
to assess the nature of the experience and establish rapport. It can also be
used to help the client distinguish between reality and the hallucination.
2. A nurse is assessing a client for signs of depression. Which of the
following findings would the nurse expect to observe?
a) Increased energy and feelings of euphoria.
b) Loss of interest in activities once enjoyed.
c) Excessive social interaction and involvement.
d) Increased need for sleep and decreased appetite.
Answer: b) Loss of interest in activities once enjoyed.
Rationale: One of the hallmark signs of depression is anhedonia, or a
loss of interest or pleasure in activities previously enjoyed.
,3. A client with generalized anxiety disorder (GAD) reports
excessive worry and restlessness. Which of the following
interventions should the nurse include in the plan of care?
a) Encourage the client to confront the source of anxiety immediately.
b) Teach the client relaxation techniques such as deep breathing.
c) Provide the client with sedatives to reduce anxiety.
d) Avoid discussing the anxiety-inducing situations to prevent
exacerbation.
Answer: b) Teach the client relaxation techniques such as deep
breathing.
Rationale: Relaxation techniques like deep breathing can help clients
manage anxiety by reducing physiological symptoms. It's important to
provide tools for managing anxiety rather than avoiding anxiety-
provoking topics.
4. A nurse is providing discharge teaching for a client diagnosed
with major depressive disorder. Which of the following statements
indicates that the client understands the teaching?
a) "I will stop taking my medication once I feel better."
b) "I will follow up with my psychiatrist regularly."
c) "I should avoid talking to my family members about my depression."
d) "I can drink alcohol in moderation while on antidepressants."
Answer: b) "I will follow up with my psychiatrist regularly."
Rationale: Ongoing follow-up care is essential for monitoring treatment
, progress, adjusting medication if needed, and ensuring the client
receives the necessary support.
5. A nurse is caring for a client who is withdrawing from alcohol.
Which of the following is the priority assessment?
a) Temperature
b) Blood pressure
c) Level of consciousness
d) Respiratory rate
Answer: b) Blood pressure
Rationale: Alcohol withdrawal can cause a significant increase in blood
pressure. This is a priority because severe hypertension can lead to
complications such as stroke or seizures.
6. A nurse is caring for a client with borderline personality disorder.
Which of the following behaviors should the nurse expect?
a) Avoidance of interpersonal relationships.
b) A tendency to manipulate others to meet their needs.
c) Inability to form close attachments to others.
d) An intense fear of abandonment and mood instability.
Answer: d) An intense fear of abandonment and mood instability.
Rationale: Individuals with borderline personality disorder typically
exhibit intense emotional instability, impulsive behavior, and a chronic
fear of abandonment.
client is experiencing auditory hallucinations. Which of the
following should the nurse do first?
a) Encourage the client to describe the voices.
b) Ignore the hallucinations and continue with the care plan.
c) Offer the client a medication to calm down.
d) Ask the client to focus on reality-based activities.
Answer: a) Encourage the client to describe the voices.
Rationale: Encouraging the client to talk about the hallucinations helps
to assess the nature of the experience and establish rapport. It can also be
used to help the client distinguish between reality and the hallucination.
2. A nurse is assessing a client for signs of depression. Which of the
following findings would the nurse expect to observe?
a) Increased energy and feelings of euphoria.
b) Loss of interest in activities once enjoyed.
c) Excessive social interaction and involvement.
d) Increased need for sleep and decreased appetite.
Answer: b) Loss of interest in activities once enjoyed.
Rationale: One of the hallmark signs of depression is anhedonia, or a
loss of interest or pleasure in activities previously enjoyed.
,3. A client with generalized anxiety disorder (GAD) reports
excessive worry and restlessness. Which of the following
interventions should the nurse include in the plan of care?
a) Encourage the client to confront the source of anxiety immediately.
b) Teach the client relaxation techniques such as deep breathing.
c) Provide the client with sedatives to reduce anxiety.
d) Avoid discussing the anxiety-inducing situations to prevent
exacerbation.
Answer: b) Teach the client relaxation techniques such as deep
breathing.
Rationale: Relaxation techniques like deep breathing can help clients
manage anxiety by reducing physiological symptoms. It's important to
provide tools for managing anxiety rather than avoiding anxiety-
provoking topics.
4. A nurse is providing discharge teaching for a client diagnosed
with major depressive disorder. Which of the following statements
indicates that the client understands the teaching?
a) "I will stop taking my medication once I feel better."
b) "I will follow up with my psychiatrist regularly."
c) "I should avoid talking to my family members about my depression."
d) "I can drink alcohol in moderation while on antidepressants."
Answer: b) "I will follow up with my psychiatrist regularly."
Rationale: Ongoing follow-up care is essential for monitoring treatment
, progress, adjusting medication if needed, and ensuring the client
receives the necessary support.
5. A nurse is caring for a client who is withdrawing from alcohol.
Which of the following is the priority assessment?
a) Temperature
b) Blood pressure
c) Level of consciousness
d) Respiratory rate
Answer: b) Blood pressure
Rationale: Alcohol withdrawal can cause a significant increase in blood
pressure. This is a priority because severe hypertension can lead to
complications such as stroke or seizures.
6. A nurse is caring for a client with borderline personality disorder.
Which of the following behaviors should the nurse expect?
a) Avoidance of interpersonal relationships.
b) A tendency to manipulate others to meet their needs.
c) Inability to form close attachments to others.
d) An intense fear of abandonment and mood instability.
Answer: d) An intense fear of abandonment and mood instability.
Rationale: Individuals with borderline personality disorder typically
exhibit intense emotional instability, impulsive behavior, and a chronic
fear of abandonment.
