MEDICATIONS
A nurse is caring for a client taking haloperidol. Which assessment finding is most concerning and requires immediate intervention?
WHAT IS MUSCLE REGIDITY AND FEVER?
A client with depression states, “I feel like nothing I do matters anymore.” Which nurse response demonstrates therapeutic communication?
A. “That’s not true—you matter a lot.”
B. “Why do you feel that way?”
C. “Tell me more about what makes you feel that way.”
D. “Everyone feels like that sometimes.”
C. “Tell me more about what makes you feel that way.”
A client with alcohol use disorder states, “I don’t have a drinking problem. I can stop anytime I want.” Which defense mechanism is the client using?
A. Projection
B. Denial
C. Rationalization
D. Suppression
B. Denial
A nurse is caring for a child diagnosed with autism spectrum disorder. Which behavior is most characteristic of this disorder?
A. Hallucinations and delusions
B. Difficulty with social interaction and communication
C. Frequent mood swings
D. Excessive fear of separation
B. Difficulty with social interaction and communication
Which symptom is required for a diagnosis of major depressive disorder?
A. Delusions
B. Elevated mood
C. Loss of interest or pleasure
D. Compulsive behaviors
C. Loss of interest or pleasure
A client taking sertraline reports restlessness, sweating, and confusion. The nurse suspects which condition?
WHAT IS SEROTONIN SYNDROME?
A client says, “I’m scared I’ll never get better.” Which response best reflects the client’s feelings?
A. “There’s no reason to feel scared.”
B. “You’re worried about your future.”
C. “You should focus on the positive.”
D. “Many clients feel this way.”
B. “You’re worried about your future.”
A client who is angry with the nurse states, “You’re the one who doesn’t like me.” Which defense mechanism is this?
B. Projection
Which finding supports a diagnosis of ADHD in a school-aged child?
A. Persistent sadness and withdrawal
B. Inattention and impulsivity across multiple settings
C. Repetitive hand movements
D. Fear of being away from caregivers
B. Inattention and impulsivity across multiple settings
A client with generalized anxiety disorder is most likely to report which symptom?
A. Sudden panic attacks
B. Excessive worry lasting at least 6 months
C. Fear of social situations
D. Flashbacks of a traumatic event
B. Excessive worry lasting at least 6 months
A nurse is teaching a client prescribed lithium carbonate. Which statement by the client indicates correct understanding?
A. “I should limit my salt intake.”
B. “I will drink at least 2–3 liters of water daily.”
C. “I can take ibuprofen for headaches.”
D. “If I miss a dose, I’ll double the next one.”
WHAT IS “I will drink at least 2–3 liters of water daily.” HYDRATION
A client with schizophrenia says, “The FBI is watching me through the TV.” What is the best therapeutic response?
C. “I don’t see any evidence of that, but I understand it feels real to you.”
A client who was reprimanded by a provider later yells at a family member. Which defense mechanism is demonstrated?
C. Displacement
A child with Tourette disorder is most likely to exhibit which symptom?
A. Intentional self-harm
B. Motor and vocal tics
C. Delayed speech development
D. Severe mood instability
B. Motor and vocal tics
Which finding differentiates bipolar I disorder from bipolar II disorder?
A. Presence of depressive episodes
B. Rapid mood changes
C. At least one manic episode
D. Cyclothymic symptoms
C. At least one manic episode
A client is prescribed lorazepam for acute anxiety. Which nursing action is most appropriate?
A. Encourage abrupt discontinuation when symptoms improve
B. Monitor for respiratory depression
C. Administer the medication at bedtime only
D. Expect increased alertness and energy
WHAT IS Monitor for respiratory depression?
A client begins crying during a therapy session and does not speak. What is the nurse’s best action?
C. Sit quietly and remain present
A client who strongly dislikes a coworker is overly friendly toward them. Which defense mechanism is this?
A. Reaction formation
Which assessment finding is consistent with intellectual developmental disorder?
A. Decline in memory after age 65
B. Difficulty with adaptive functioning and academic skills
C. Persistent hallucinations
D. Sudden loss of speech
B. Difficulty with adaptive functioning and academic skills
Which symptom is considered a negative symptom of schizophrenia?
A. Hallucinations
B. Delusions
C. Flat affect
D. Disorganized speech
C. Flat affect
Which side effect is the nurse most likely to monitor in a client taking olanzapine?
Weight gain and hyperglycemia
A client with mania is interrupting other clients during group therapy. Which response by the nurse is most appropriate?
A. “You need to stop talking right now.”
B. “You’re being rude to others.”
C. “Please wait until others finish speaking before you talk.”
D. “Why are you interrupting everyone?”
C. “Please wait until others finish speaking before you talk.”
After failing an exam, a student says, “That test was unfair anyway.” Which defense mechanism is being used?
C. Rationalization
Which example best demonstrates an expressive language disorder?
A. Difficulty understanding spoken instructions
B. Inability to form complete sentences when speaking
C. Repetitive vocal tics
D. Lack of eye contact
B. Inability to form complete sentences when speaking
Which statement best describes obsessive-compulsive disorder?
A. Impulsive behaviors without anxiety
B. Recurrent thoughts followed by repetitive behaviors
C. Fixed false beliefs
D. Mood instability and irritability
B. Recurrent thoughts followed by repetitive behaviors