Anxiety
A client with panic disorder is pacing, hyperventilating, and shouting, “I can’t breathe! I’m dying!” What is the nurse’s priority action?
A. Teach deep breathing exercises
B. Stay with the client and reduce stimuli
C. Ask what triggered the panic attack
D. Administer PRN antidepressants
Answer: B
Rationale: During panic-level anxiety, the priority is to remain with the client and reduce stimuli because the client cannot process teaching or discuss triggers until anxiety decreases.
A client with schizophrenia says, “The voices are telling me to kill myself.” What is the nurse’s priority response?
A. “The voices are not real.”
B. “What are the voices saying?”
C. “Do you have a plan to harm yourself?”
D. “Try to ignore the voices.”
Answer: C
Rationale: The priority is assessing immediate safety risk.
A client with depression says, “Everyone would be better off without me.” What is the nurse’s priority response?
A. “Why do you feel that way?”
B. “Are you thinking of hurting yourself?”
C. “You should not say that.”
D. “Let’s talk about something positive.”
Answer: B
Rationale: The priority is assessing suicide risk.
A client with rheumatoid arthritis reports severe joint pain and swelling. What is the nurse’s priority intervention?
A. Encourage exercise
B. Administer anti-inflammatory medication
C. Apply heat after ambulation
D. Restrict fluids
Answer: B
Rationale: Reducing inflammation is priority.
A neutropenic client develops a fever of 101°F. Priority?
A. Administer antibiotics as ordered
B. Offer fluids
C. Recheck temp later
D. Encourage ambulation
Answer: A
Rationale: Fever in neutropenia is an emergency.
An older adult becomes acutely confused and restless 12 hours after surgery. What is the nurse’s priority action?
A. Reorient the client
B. Assess oxygen saturation
C. Apply restraints
D. Administer a sedative
Answer: B
Rationale: For an older adult who becomes acutely confused after surgery, the priority is to assess oxygen saturation because hypoxia is a common reversible cause of postoperative delirium.
A client begins pacing rapidly, shouting, and clenching fists during group therapy. What is the nurse’s priority action?
A. Approach calmly and attempt verbal de-escalation
B. Call security immediately
C. Restrain the client
D. Ask the client to leave the room
Answer: A
Rationale: For a client who is pacing, shouting, and clenching fists, the priority is calm verbal de-escalation because early intervention may prevent escalation to violence.
A client arrives in the emergency department with bruising to the arms and ribs. The partner answers all questions for the client and refuses to leave the room. What is the nurse’s priority action?
A. Ask the partner to step out so the client can be assessed privately
B. Ask the client in front of the partner whether the injuries were accidental
C. Document the bruises and continue the admission assessment
D. Notify security to escort the partner out of the hospital
Answer: A
Rationale: For a client with possible intimate partner violence whose partner refuses to leave, the priority is to separate the client from the partner to allow for safe, private assessment. Direct questioning in front of the partner may place the client at greater risk.
A nurse is caring for a client with generalized anxiety disorder prescribed lorazepam. Which findings indicate side effects of this medication? Select all that apply.
A. Drowsiness
B. Respiratory depression
C. Increased alertness
D. Hypotension
E. Insomnia
Answer: A, B, D
Rationale: Lorazepam is a benzodiazepine that can cause sedation, respiratory depression, and hypotension.
Which are positive symptoms of schizophrenia? Select all that apply.
A. Hallucinations
B. Delusions
C. Flat affect
D. Disorganized speech
E. Social withdrawal
Answer: A, B, D
Rationale: Positive symptoms include hallucinations, delusions, and disorganized speech.
Which findings are associated with mania? Select all that apply.
A. Grandiosity
B. Decreased sleep
C. Pressured speech
D. Flat affect
E. Flight of ideas
Answer: A, B, C, E
Rationale: Mania includes grandiosity, decreased sleep, pressured speech, and flight of ideas.
Ibuprofen reduces inflammation by inhibiting ________.
Word Bank: prostaglandins, histamine, insulin, sodium
Answer: prostaglandins
Rationale: NSAIDs inhibit prostaglandin synthesis.
Anaphylaxis is treated first with ________.
Word Bank: epinephrine, diphenhydramine, prednisone, albuterol
Answer: epinephrine
A nurse is assessing a client with delirium. Which findings should the nurse expect? Select all that apply.
A. Acute onset
B. Fluctuating alertness
C. Progressive memory loss
D. Disorganized thinking
E. Inattention
Answer: A, B, D, E
Rationale: For a client with delirium, expected findings include acute onset, fluctuating level of consciousness, disorganized thinking, and inattention. Progressive memory loss is more characteristic of dementia.
When attempting to calm an aggressive client, the nurse should use a ________ tone of voice.
Word Bank: calm, loud, even, rapid
Answer: calm
Rationale: For an aggressive client, using a calm tone helps reduce stimulation and decreases the chance of escalation.
An older adult is admitted with dehydration, pressure injuries, and poor hygiene. The caregiver states, “It’s hard to keep up with everything.” What is the nurse’s priority action?
A. Notify adult protective services after completing the assessment
B. Assess the client for neglect and ensure immediate care needs are met
C. Ask the caregiver if they want respite care resources
D. Educate the caregiver about proper hygiene and nutrition
Answer: B
Rationale: For an older adult with signs of possible neglect, the priority is to assess for neglect while addressing immediate physiological needs such as dehydration and skin breakdown. Safety and urgent care come before reporting or teaching.
A client taking sertraline reports agitation, sweating, tremors, and confusion. The nurse suspects ________ syndrome.
Word Bank: serotonin, neuroleptic, lithium, withdrawal
Answer: serotonin
Rationale: These are symptoms of serotonin syndrome, a potentially life-threatening adverse effect of SSRIs.
A client taking haloperidol develops neck spasms and jaw stiffness. The nurse recognizes ________ symptoms.
Word Bank: EPS, NMS, serotonin, anticholinergic
Answer: EPS
Rationale: Acute dystonia is an extrapyramidal symptom (EPS).
A therapeutic lithium level is ________ to ________ mEq/L.
Word Bank: 0.6, 1.2, 1.8, 2.5
Answer: 0.6 to 1.2
Rationale: The therapeutic range for lithium is 0.6–1.2 mEq/L.
A client on prednisone develops a fever. Priority?
A. Give acetaminophen
B. Notify provider
C. Increase dose
D. Encourage rest
Answer: B
Rationale: Steroids suppress immunity; fever may indicate infection.
A nurse is caring for a client newly diagnosed with HIV who asks, “Why do I need all these blood tests?” Which response by the nurse is best?
A. “The tests are used to determine whether your HIV is curable.”
B. “The tests monitor your CD4 count and viral load to evaluate immune function.”
C. “The tests determine whether you have developed immunity to HIV.”
D. “The tests are used only to determine medication dosage.”
Answer: B
Rationale: For a client newly diagnosed with HIV, CD4 count and viral load are monitored to evaluate immune system status and disease progression. HIV is not curable, and antibodies do not provide immunity.
A client with Alzheimer’s disease is prescribed ________, a medication used to slow cognitive decline.
Word Bank: donepezil, haloperidol, lorazepam, fluoxetine
Answer: donepezil
Rationale: For a client with Alzheimer’s disease, donepezil is used to improve cognition by increasing acetylcholine levels in the brain.
A client suddenly swings at a staff member. What is the nurse’s priority intervention?
A. Initiate emergency safety procedures
B. Ask the client what caused the anger
C. Administer oral medication
D. Leave the client alone
Answer: A
Rationale: For a client who becomes physically violent, emergency safety procedures are the priority to protect staff and the client from injury.
A child admitted with a fractured arm says quietly, “Please don’t tell my dad I said anything.” What is the nurse’s best response?
A. “I will not tell anyone what you said.”
B. “You are safe here, and I need to share concerns to help keep you safe.”
C. “Why are you afraid of your dad?”
D. “Your dad cannot hurt you anymore.”
Answer: B
Rationale: For a child expressing fear related to possible abuse, the nurse should provide reassurance while explaining that concerns must be reported to maintain safety. Promising secrecy is inappropriate.
A client with OCD becomes severely distressed when the nurse interrupts a handwashing ritual. What is the best response?
A. “You need to stop this behavior now.”
B. “Why do you feel the need to wash your hands?”
C. “I can see this is upsetting. Let’s talk after you finish.”
D. “Your hands are already clean.”
Answer: C
Rationale: Allowing the ritual temporarily reduces anxiety and promotes therapeutic communication.
A client on clozapine develops a fever and sore throat. What is the nurse’s priority action?
A. Administer acetaminophen
B. Notify the provider immediately
C. Encourage fluids
D. Reassure the client
Answer: B
Rationale: Clozapine can cause agranulocytosis, requiring immediate evaluation.
A client taking lithium has vomiting, diarrhea, tremors, and confusion. What is the priority action?
A. Give next dose
B. Hold medication and notify provider
C. Encourage caffeine
D. Restrict sodium
Answer: B
Rationale: These indicate lithium toxicity.
Client with inflammation reports black tarry stools while taking naproxen. Priority?
A. Hold medication and notify provider
B. Encourage fluids
C. Give antacid
D. Continue therapy
Answer: A
Rationale: Black stools suggest GI bleeding.
A nurse is teaching a client about pre-exposure prophylaxis (PrEP) for HIV prevention. Which statements indicate understanding? Select all that apply.
A. “PrEP is taken before possible HIV exposure.”
B. “PrEP can replace condom use.”
C. “PrEP reduces the risk of HIV infection.”
D. “PrEP must be taken consistently to be effective.”
E. “PrEP is used after accidental exposure.”
Answer: A, C, D
Rationale: For a client taking PrEP, the medication is taken before exposure and must be taken consistently to reduce HIV transmission risk. It does not replace condoms and is not used after exposure.
A nurse is reinforcing discharge teaching for a client newly diagnosed with Meniere’s disease. Which statement by the client indicates a need for further teaching?
A. “I should avoid foods high in sodium, such as canned soups and processed meats.”
B. “I will change positions slowly during vertigo episodes to reduce my risk of falling.”
C. “I should drink extra fluids when symptoms occur to improve inner ear circulation.”
D. “I will limit caffeine and alcohol intake because they may trigger symptoms.”
Answer: C
Rationale: For a client with Meniere’s disease, drinking extra fluids during symptom episodes is not recommended because treatment focuses on reducing fluid buildup in the inner ear. Limiting sodium, changing positions slowly, and avoiding caffeine/alcohol are appropriate measures to reduce vertigo attacks.
A client reports intimate partner violence and has visible bruising. What is the nurse’s priority intervention?
A. Ensure the client’s immediate safety
B. Notify the police
C. Contact the abuser
D. Ask why the client stayed
Answer: A
Rationale: For a client reporting intimate partner violence, immediate safety is the priority before any additional interventions.
A nurse suspects intimate partner violence in a client. Which findings increase the nurse’s suspicion? Select all that apply.
A. The client delays seeking treatment for injuries
B. The client makes eye contact and speaks confidently
C. The partner answers questions for the client
D. The explanation for injuries is inconsistent
E. The client appears fearful when the partner is present
Answer: A, C, D, E
Rationale: For a client experiencing intimate partner violence, delayed treatment, inconsistent explanations, fearful behavior, and controlling partner behavior are red flags for abuse.
A client taking venlafaxine reports suicidal thoughts after starting therapy 1 week ago. What is the nurse’s priority action?
A. Reassure this is normal
B. Notify the provider immediately
C. Encourage journaling
D. Hold the medication for 24 hours
Answer: B
Rationale: Antidepressants may initially increase suicidal thoughts. This requires immediate provider notification.
A client prescribed risperidone develops a temperature of 103°F, muscle rigidity, and confusion. What is the priority?
A. Give benztropine
B. Hold medication and notify provider
C. Offer fluids
D. Reassure the client
Answer: B
Rationale: These are signs of neuroleptic malignant syndrome, a medical emergency.
A manic client has not eaten in 2 days due to constant activity. What is priority?
A. Encourage a large dinner
B. Offer high-calorie finger foods
C. Teach nutrition
D. Provide group meals
Answer: B
Rationale: Manic clients need portable, high-calorie foods.
Which adverse effects are expected with corticosteroids? Select all that apply.
A. Hyperglycemia
B. Weight gain
C. Hypertension
D. Bradycardia
E. Increased infection risk
Answer: A, B, C, E
A nurse caring for a healthcare worker exposed to HIV through a needlestick knows that ________ should be started within ________ hours of exposure.
Word Bank: PEP, PrEP, 72, 7
Answer: PEP, 72
Rationale: After occupational HIV exposure, post-exposure prophylaxis (PEP) should be started within 72 hours to reduce infection risk.
A nurse prepares to administer timolol ophthalmic drops to a client with glaucoma. The client’s blood pressure is 100/64 mmHg, apical pulse is 54/min, and the client reports feeling “lightheaded when standing.” What is the nurse’s best action?
A. Administer the medication and reassess the pulse in 30 minutes
B. Hold the medication and notify the provider
C. Administer the medication and instruct the client to rise slowly
D. Hold the medication and recheck the blood pressure in 1 hour
Answer: B
Rationale: For a client receiving timolol eye drops with bradycardia and orthostatic symptoms, the best action is to hold the medication and notify the provider because timolol can be systemically absorbed and worsen bradycardia and hypotension.
Which findings may indicate abuse? Select all that apply.
A. Multiple bruises in various healing stages
B. Fearful behavior around partner
C. Delayed treatment for injuries
D. Consistent explanation of injuries
E. Frequent emergency visits
Answer: A, B, C, E
Rationale: For a client experiencing abuse, injuries in various stages, fearfulness, delayed treatment, and repeated emergency visits are common warning signs.
A client reports that their partner “gets violent when angry” but says, “I’m not ready to leave.” What is the nurse’s best response?
A. “You need to leave before the violence gets worse.”
B. “Let’s talk about a safety plan for when you feel at risk.”
C. “Why are you staying in the relationship?”
D. “I will contact law enforcement now.”
Answer: B
Rationale: For a client experiencing intimate partner violence who is not ready to leave, the best intervention is to develop a safety plan. Pressuring the client may increase danger and reduce trust.
The nurse should instruct a client taking alprazolam to avoid alcohol because it increases the risk for ________ depression.
Word Bank: respiratory, renal, cardiac, hepatic
Answer: respiratory
Rationale: Alcohol and benzodiazepines together increase the risk of respiratory depression.
The therapeutic communication technique for a client experiencing delusions is ________ orientation.
Word Bank: reality, emotional, cognitive, behavioral
Answer: reality
Rationale: Reality orientation helps acknowledge feelings without validating delusions.
A client taking fluoxetine should be monitored for ________ thoughts, especially early in treatment.
Word Bank: suicidal, homicidal, obsessive, paranoid
Answer: suicidal
Rationale: SSRIs may increase suicidal thoughts early in therapy.
Which are signs of inflammation? Select all that apply.
A. Redness
B. Swelling
C. Heat
D. Pallor
E. Pain
Answer: A, B, C, E
Rationale: Classic inflammation signs are redness, swelling, heat, and pain.
A client with HIV has a CD4 count of 180 cells/mm³. Which nursing intervention is the priority?
A. Encourage fresh fruits and flowers in the room
B. Initiate protective precautions and monitor for infection
C. Restrict all visitors
D. Delay vaccinations indefinitely
Answer: B
Rationale: For a client with a CD4 count of 180, the priority is infection prevention because severe immunosuppression increases the risk for opportunistic infections.
A client with acute angle-closure glaucoma reports sudden severe eye pain, blurred vision, and seeing halos around lights. What is the nurse’s priority action?
A. Notify the provider immediately
B. Dim the lights and reassess in 30 minutes
C. Encourage the client to rest
D. Administer artificial tears
Answer: A
Rationale: For a client with acute angle-closure glaucoma who reports sudden severe eye pain and blurred vision, notifying the provider immediately is the priority because increased intraocular pressure can rapidly lead to permanent vision loss.
A suicidal client begins threatening staff and other clients. What is the nurse’s priority action?
A. Protect all clients and staff immediately
B. Ask the client why they are angry
C. Reduce the observation level
D. Offer the client privacy
Answer: A
Rationale: For a suicidal client who threatens violence, immediate protection of all clients and staff is the priority.
A 4-year-old child is brought to the clinic with bruises on the back and upper thighs. The parent states the child “falls a lot.” What is the nurse’s best action?
A. Ask the child privately how the bruises happened
B. Document findings and report suspected abuse per policy
C. Tell the parent the injuries appear suspicious
D. Discharge the child with instructions for supervision
Answer: B
Rationale: For a child with bruising patterns suspicious for abuse, the nurse should document findings objectively and report suspected abuse according to policy. The nurse is mandated to report suspicion, not prove abuse.