seizures
Which nursing intervention is most important for a client with a history of generalized tonic-clonic seizures?
A. Keep padded side rails up at all times.
B. Place a tongue blade at the bedside.
C. Restrain the client during seizure activity.
D. Administer oral medication during seizure onset.
A.
Safety is the priority — maintain airway, prevent injury (padded side rails, turn on side after seizure). Never restrain the client or insert objects into their mouth.
A client is admitted after a motor vehicle accident with suspected diffuse axonal injury (DAI). Which finding should the nurse expect?
A. Rapidly improving neurological function
B. Prolonged coma with minimal recovery
C. Localized motor weakness on one side
D. Fixed dilated pupils and brainstem death
Answer: B.
DAI involves widespread shearing of axons, often causing coma lasting weeks to months with poor prognosis.
The nurse is assessing a client with bipolar mania. Which finding is most characteristic of this phase?
A. Lethargy, hopelessness, and indecisiveness
B. Pressured speech and flight of ideas
C. Flat affect and anhedonia
D. Suspiciousness and social withdrawal
B.
Pressured speech, flight of ideas, inflated self-esteem, and decreased sleep are hallmark signs of mania in bipolar I.
A nurse at a Medical Center is developing a care plan for a female client with post-traumatic stress disorder. Which of the following would she do initially?
A. Instruct the client to use distraction techniques to cope with flashbacks.
B. Encourage the client to put the past in proper perspective.
C. Encourage the client to verbalize thoughts and feelings about the trauma.
D. Avoid discussing the traumatic event with client
C.
Planning care for a client with PTSD would involve helping the client to verbalize thoughts and feelings about the trauma. This will help the client work through the strong emotions connected with the trauma and, therefore foster the belief that she is able to cope. Avoiding discussion and using distraction techniques would be inappropriate.
Option B may be possible later, after the client is able to verbalize strong emotions
a type of disorder where pt creates intentional signs & symptoms to gain attention or sympathy
Factitious Disorder
A client with active TB is hospitalized. Which action indicates proper infection control by the nurse?
A. Place the client in a negative-pressure room and wear an N95 respirator.
B. Place the client on contact precautions and use sterile gloves.
C. Assign the client to a semi-private room with another TB patient.
D. Keep the door open to improve airflow.
Answer: A.
TB = airborne precautions → negative pressure + N95. Door must remain closed.
Four clients are in the mental-health unit. Who should the nurse see first?
A. PTSD client pacing and muttering about “the desert” but redirectable
B. OCD client washing hands for 30 minutes
C. Depression client refusing breakfast
D. PTSD client suddenly quiet, withdrawn, and giving away personal items
Answer: D.
Sudden calmness + giving away items = imminent suicide risk — highest priority for safety.
A patient with major depressive disorder has been prescribed an SSRI for 3 weeks. They report increased irritability and state, “I feel worse than before I started.”
Which action should the nurse take first?
A. Encourage continuation of the medication for at least 2 more weeks.
B. Assess for suicidal thoughts or self-harm.
C. Teach the patient about dietary restrictions with SSRIs.
D. Suggest adding an over-the-counter supplement to boost mood.
B – SSRIs can temporarily increase suicidal thoughts; the nurse must assess for risk before continuing therapy.
A 10-year-old child is hospitalized for asthma. When the child sees a new nurse, they suddenly begin thumb-sucking, clinging to their parent, and using baby talk, behaviors they had long outgrown.
Which defense mechanism is the child exhibiting?
A. Projection
B. Regression
C. Displacement
D. Rationalization
Answer: B
Regression occurs when an individual reverts to an earlier stage of development in response to stress or anxiety.
The child’s thumb-sucking, clinging, and baby talk are immature coping behaviors triggered by hospitalization stress.
A nurse is teaching a client taking phenytoin (Dilantin) about medication management. Which statement by the client shows understanding?
A. “I can stop taking it once I haven’t had a seizure for a few months.”
B. “I should brush and floss carefully because this medicine can cause gum problems.”
C. “If I feel drowsy, I should double my dose next time.”
D. “I’ll take it with antacids to protect my stomach.”
B.
Phenytoin commonly causes gingival hyperplasia (overgrowth of gum tissue), so good oral hygiene is essential. It should never be stopped abruptly, doses should not be adjusted independently, and antacids can interfere with absorption.
A client with a severe traumatic brain injury (TBI) is being monitored for increased intracranial pressure (ICP). Which finding would be the most concerning and requires immediate intervention?
A. Restlessness and headache
B. Projectile vomiting without nausea
C. Pupils equal and reactive to light
D. Heart rate 92 bpm, BP 118/70 mm Hg
Correct Answer: B.
Rationale: Projectile vomiting without nausea is a classic sign of rising ICP due to pressure on the brainstem. This requires rapid intervention to prevent herniation.
A nurse suspects a patient with bipolar II disorder is entering a hypomanic episode. Which observation supports this?
A. The client exhibits psychosis and hypersexuality.
B. The client is mildly euphoric and sleeping less but functioning.
C. The client has pressured speech and is not sleeping for days.
D. The client has withdrawn and is mute.
B.
Hypomania (Bipolar II) = less severe, shorter duration (<4 days), no psychosis or major impairment.
Bipolar I = full mania with psychosis and dysfunction.
A group of community nurses sees and plans care for various clients with different types of problems. Which of the following clients would they consider the most vulnerable to post-traumatic stress disorder?
A. An 8 year-old boy with asthma who has recently failed a grade in school
B. A 20 year-old college student with DM who experienced date rape
C. A 40 year-old widower who has recently lost his wife to cancer
D. A wife of an individual with a severe substance abuse problem
B.
PTSD is caused by the the experience of severe, specific trauma. Rape is a severely traumatic event. Although the situations in options A, C, and D are certainly stressful, they are not at the level of severe trauma.
A 28-year-old client is admitted for evaluation after suddenly losing the ability to move their right arm. Diagnostic tests reveal no neurological or physiological cause for the paralysis. The client calmly tells the nurse, “It’s fine, I guess my arm just stopped working,” and shows no apparent distress about the loss of function.
Which nursing interpretation is most appropriate?
A. The client’s calmness suggests denial, a common early reaction to acute illness.
B. The client is demonstrating la belle indifférence, a characteristic response in conversion disorder.
C. The client is likely exaggerating symptoms to gain attention from staff.
D. The client is showing depersonalization, often seen in dissociative disorders.
B.
Answer: B
La belle indifférence refers to an inappropriate lack of concern or indifference toward physical symptoms that cause significant functional impairment.
Denial (A) and depersonalization (D) are different phenomena, and assuming malingering (C) is nontherapeutic and judgmental.
A nurse in a community clinic is preparing to implement Directly Observed Therapy (DOT) for a client newly diagnosed with active pulmonary TB. Which statement by the client indicates a need for further teaching?
A. “Someone will watch me take my TB medicine every day.”
B. “This program helps make sure I finish my treatment.”
C. “If I start feeling better, I can stop the medicine as long as I let the nurse know.”
D. “DOT helps prevent spreading resistant TB strains.”
Answer: C.
Stopping meds early, even with permission is unsafe. DOT ensures full completion to prevent multidrug resistance and relapse.
recurrent & persistant thoughts, urges, or impulses that are experienced as intrusive & unwanted that can cause anxiety or distress
Obsessions
A 32-year-old patient reports feeling “empty” for the past 3 weeks, has lost 10 pounds without trying, struggles with concentration at work, and admits to thoughts of “being better off dead.”
Which nursing action is the highest priority?
A. Encourage the patient to attend a support group.
B. Discuss dietary changes to improve mood.
C. Assess the patient’s suicide risk.
D. Teach relaxation techniques for stress reduction.
Answer: C
Safety always comes first. Any patient expressing suicidal thoughts must be assessed for risk and monitored closely. Interventions like support groups or relaxation are secondary.
A father comes home from work upset about a reprimand from his supervisor and then yells at his teenage child over minor mistakes.
What defense mechanism is the father displaying?
A. Denial
B. Rationalization
C. Projection
D. Displacement
D.
Displacement occurs when emotions are redirected from the original source to a safer or more convenient target. The father cannot express anger toward the supervisor, so it is redirected toward the child.
A nurse prepares to administer IV phenytoin to a client with status epilepticus. Which order should the nurse question?
A. “Dilute the medication in normal saline.”
B. “Administer IV push at 100 mg/min.”
C. “Use a large-bore IV in a dedicated line.”
D. “Monitor cardiac rhythm continuously.”
Answer: B.
Rationale: IV phenytoin must be given slowly (no faster than 50 mg/min) due to risk of severe hypotension, bradycardia, and cardiac arrest. Always use normal saline and continuous ECG monitoring.
The nurse is assessing a client with a recent concussion. Which finding should be reported to the healthcare provider immediately?
A. Headache that improves with rest
B. Nausea and mild dizziness
C. Repeated vomiting and difficulty waking up
D. Temporary short-term memory loss
Answer: C.
Repeated vomiting and increasing drowsiness suggest worsening ICP or intracranial bleeding, not a simple concussion. Notify the provider immediately.
A person is directing traffic on a busy street while shouting & making obscene gestures at passing cars. The person has not slept or eaten for 3 days. What features of mania are evident?
a. Increased muscle tension and anxiety
b. Vegetative signs and poor grooming
c. Poor judgment and hyperactivity
d. Cognitive deficit and sad mood
C.
Hyperactivity (directing traffic) & poor judgment (putting self in a dangerous position) are characteristic of manic episodes. The distractors do not specifically apply to mania.
A client with PTSD after sexual assault says, “It’s my fault. I should have fought harder.”
Which nurse response is most appropriate?
A. “You did what you had to do to survive.”
B. “Try not to think that way; it’ll only make you feel worse.”
C. “You shouldn’t blame yourself for what happened.”
D. “Why do you feel responsible for the assault?”
Answer: A.
PTSD often involves guilt and self-blame. The therapeutic response should validate the experience and shift focus from blame to survival.
(B) Dismisses the feeling.
(C) Although supportive, it’s too directive (“you shouldn’t”) and not validating.
(D) Asking “why” can sound judgmental and increase shame.
A nurse is caring for a client diagnosed with Dissociative Identity Disorder (DID). During the interview, one personality refers to the nurse by a different name and insists the nurse worked with them years ago.
Which nursing action is most appropriate?
A. Correct the client firmly and remind them who you are.
B. Acknowledge the client’s perception and gently orient them to the present setting.
C. Confront the client about the inconsistency between personalities.
D. Ignore the behavior and proceed with assessment questions.
B.
The nurse should acknowledge the client’s perception and gently orient them to reality. Firm correction or confrontation can increase anxiety and dissociation.
A client on RIPE therapy reports blurred vision and difficulty distinguishing red from green. Which action is most appropriate?
A. Document findings as expected with treatment.
B. Advise the client to avoid bright lights.
C. Hold the medication and notify the provider.
D. Administer vitamin B6 as prescribed.
Answer: C.
These are signs of optic neuritis from ethambutol → can lead to permanent vision loss. Must stop drug immediately.
A nurse is caring for a client with OCD who spends several hours each day washing their hands. The nurse should first:
A. Encourage the client to immediately stop washing their hands
B. Allow the client to perform the ritual, then gradually set limits on the time
C. Distract the client with another activity when they begin the ritual
D. Explain that the ritual reinforces the anxiety and must be stopped
Answer: B
In OCD, rituals are anxiety-reducing coping mechanisms. The initial goal is not to stop them abruptly (which increases anxiety) but to gradually limit and replace rituals with healthier coping behaviors through exposure and response prevention (ERP).
How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)?
A. GAD is acute in nature, and panic disorder is chronic.
B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders.
C. Hyperventilation is a common symptom in GAD and rare in panic disorder.
D. Depersonalization is commonly seen in panic disorder and absent in GAD.
D. Depersonalization is commonly seen in panic disorder and absent in GAD.
The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.
A 42-year-old patient who yelled at their spouse in the morning brings home flowers and apologizes profusely in the evening, saying, “I just want to make things right.” The patient reports feeling intense guilt over the earlier conflict.
Which statement best demonstrates that the patient is using “undoing” as a defense mechanism?
A. The patient is denying that the conflict ever occurred.
B. The patient is channeling anger into physical activity to reduce guilt.
C. The patient is attempting to reverse or “cancel out” unacceptable behavior with a symbolic gesture.
D. The patient is projecting their anger onto another family member.
C
Undoing is an ego defense mechanism in which a person tries to reverse or “undo” an unacceptable thought, feeling, or behavior by performing a symbolic act. In this case, the flowers and apology are the patient’s attempt to “cancel out” the earlier aggression.
The nurse is caring for a patient experiencing a tonic-clonic seizure. Which nursing actions are appropriate? (Select 4 that apply)
A. Loosen restrictive clothing.
B. Insert an oral airway immediately.
C. Turn the client onto their side after seizure stops.
D. Record the duration of seizure activity.
E. Apply restraints if the patient becomes agitated.
F. Keep the head and body safe from injury.
Answers: A, C, D, F
Safety first — protect from injury, time the seizure, and position on the side post-seizure. Never restrain or insert anything into the mouth during the event.
A nurse is caring for a client with a suspected epidural hematoma after head trauma. The patient was initially unconscious, then awake and talking, but now becomes lethargic and has a blown pupil on one side. What is the priority nursing action?
A. Check blood glucose
B. Prepare for immediate craniotomy
C. Administer IV mannitol
D. Continue to monitor neurological status every 15 minutes
Answer: B.
This pattern of brief lucidity followed by rapid deterioration is classic for epidural hematoma. Emergency surgical evacuation is the only definitive treatment.
The nurse is caring for a client receiving lithium carbonate for bipolar disorder. Which statement by the client indicates a need for further teaching?
A. “I’ll make sure to drink plenty of water every day.”
B. “I should limit foods high in sodium.”
C. “If I have vomiting or diarrhea, I’ll call my provider.”
D. “It might take a few weeks before I feel better.”
Answer: B.
Lithium and sodium compete for reabsorption.
Low sodium → ↑ lithium retention → toxicity. Patients should maintain consistent sodium intake, not restrict it.
A PTSD client tells the nurse, “I can’t live like this anymore. The only way to stop the nightmares is to end it.”
What is the nurse’s best response?
A. “You’ve felt hopeless before and survived; you’ll get through this too.”
B. “Tell me more about how you would end your life.”
C. “I’ll notify your provider that your medications aren’t working.”
D. “Try focusing on something positive when you feel that way.”
Answer: B.
This is suicidal ideation — the nurse must assess plan, means, and intent. Always assess before intervening.
A 35-year-old patient repeatedly visits the clinic reporting severe abdominal pain, headaches, and fatigue. Lab tests and imaging consistently return normal results. The patient expresses frustration that "no one believes how sick I am" and requests multiple specialist referrals.
Which nursing intervention is the priority?
A. Educate the patient on stress reduction and mindfulness techniques.
B. Validate the patient’s experience while focusing on functional improvement.
C. Encourage the patient to confront psychological stressors causing symptoms.
D. Limit the number of visits to discourage attention-seeking behavior.
Answer: B ✅
In SSD, patients genuinely experience distressing symptoms. The nurse should validate the patient’s distress while gently redirecting care toward functional improvement, rather than focusing solely on eliminating symptoms. Limiting visits or confronting stressors too directly can worsen mistrust or anxiety.
The nurse teaches a client starting isoniazid (INH). Which instruction should the nurse include?
A. “Take this medication with food or milk.”
B. “Avoid foods high in tyramine like cheese and cured meats.”
C. “Take this with an aluminum-containing antacid.”
D. “You don’t need vitamin supplements with this medication.”
Answer: B.
INH + tyramine → hypertensive crisis (interferes with monoamine metabolism). Take on empty stomach; avoid antacids; supplement with vitamin B6.
A nurse identifies which nursing diagnosis as highest priority for a client with severe OCD who spends hours performing cleaning rituals?
A. Impaired social interaction
B. Ineffective coping
C. Risk for impaired skin integrity
D. Anxiety
Answer: C
When rituals cause physical harm (e.g., dermatitis from excessive washing), safety and physiological integrity take precedence over psychological needs.
A patient experiences panic attacks when leaving the house. They report nausea, trembling, and dizziness whenever they try to go outside.
Which nursing intervention is most appropriate initially?
A. Gradually expose the patient to leaving the house with support.
B. Reassure the patient that panic attacks are harmless.
C. Recommend avoiding leaving the house entirely.
D. Focus on long-term cognitive-behavioral therapy without immediate support.
A – Gradual exposure with support is the first-line treatment for agoraphobia with panic attacks. Complete avoidance is maladaptive.
A patient misses a cardiac appointment and tells the nurse, “I didn’t go because the doctor probably wasn’t going to find anything wrong anyway.”
Which defense mechanism is the patient using?
A. Denial
B. Rationalization
C. Displacement
D. Projection
B.
Rationalization involves creating a logical or socially acceptable explanation for behavior instead of acknowledging the true underlying reason. The patient avoids admitting fear or procrastination by giving a “reason” that seems reasonable.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the
mouth of a client having a tonic-clonic seizure. Which action should the primary
nurse take?
A. Help the UAP to insert the oral airway in the mouth.
B. Tell the UAP to stop trying to insert anything in the mouth.
C. Take no action because the UAP is handling the situation.
D Notify the charge nurse of the situation immediately.
B. The nurse should tell the UAP to
stop trying to insert anything in the
mouth of the client experiencing a
seizure. Broken teeth and injury to the lips and tongue may result from
trying to place anything in the
clenched jaws of a client having a
tonic-clonic seizure.
A patient with increased ICP is receiving mannitol IV. Which assessment finding indicates the medication is effective?
A. Serum osmolality 270 mOsm/kg
B. Decreased urine output
C. Increased Glasgow Coma Scale (GCS) score
D. Weight gain of 2 lb in 24 hours
Answer: C.
Improved neurological status (↑ GCS) shows mannitol is working by reducing cerebral edema. Osmolality should rise slightly (not fall).
A nurse observes that a patient with bipolar disorder in the manic phase is constantly pacing the hallways. Which outcome should the nurse set as priority?
A. The client will verbalize feelings of anxiety.
B. The client will maintain adequate fluid and caloric intake.
C. The client will avoid conflict with other patients.
D. The client will sleep at least 6 hours per night.
B.
Physiological needs (nutrition, hydration) come first in mania due to high activity and poor intake.
The nurse recognizes which of the following as characteristic symptoms of PTSD? (Select all that apply.)
A. Persistent avoidance of trauma reminders
B. Re-experiencing the event through flashbacks
C. Decreased startle response to loud noises
D. Feelings of detachment or emotional numbness
E. Obsessions and compulsions
F. Hypervigilance and irritability
Answers: A, B, D, F
Core PTSD features:
A: Avoidance
B: Re-experiencing
D: Emotional numbing
F: Hyperarousal (irritability, sleep issues)
(C) Incorrect — startle response is increased, not decreased.
(E) Obsessions/compulsions = OCD, not PTSD.
A client with a history of sexual assault presents with nightmares, flashbacks, and avoidance of relationships. Which assessment finding would make the nurse question a PTSD diagnosis and consider dissociative identity disorder (DID) instead?
A. Emotional numbing and detachment
B. Memory gaps for major portions of the trauma
C. Hypervigilance in crowded areas
D. Startle response to loud noises
Answer: B.
Amnesia for large time periods suggests dissociative disorder, not PTSD. PTSD usually includes intrusive memories, not total loss.
After 2 months of RIPE therapy, the nurse reviews results:
ALT/AST: 180 U/L (↑)
Bilirubin: 3.2 mg/dL (↑)
Sputum: negative for AFB
Which action should the nurse take first?
A. Continue therapy since the sputum is negative.
B. Notify the provider of elevated liver enzymes.
C. Document and recheck in 1 month.
D. Discontinue rifampin immediately.
Answer: B.
Hepatotoxicity (likely from isoniazid, rifampin, or pyrazinamide) → must notify provider for possible drug adjustment.
A client with OCD is starting exposure and response prevention (ERP) therapy. Which outcome best indicates the therapy is effective?
A. The client avoids discussing their rituals
B. The client reports less anxiety when prevented from performing rituals
C. The client continues to perform rituals but hides them
D. The client stops performing all rituals after one session
Answer: B
ERP gradually exposes the client to triggers without allowing ritual performance, helping reduce anxiety and dependence on compulsions.
While taking the TCA, the patient also reports urinary retention and constipation for several days. The nurse notes tachycardia and dry mucous membranes.
Which nursing action is most appropriate?
A. Educate the patient to increase fiber and fluid intake only.
B. Notify the provider immediately, as severe anticholinergic toxicity may be developing.
C. Reassure the patient these are normal side effects and continue the medication.
D. Recommend taking the TCA with meals to reduce gastrointestinal upset.
B.
Urinary retention, constipation, tachycardia, and dry mucous membranes may indicate severe anticholinergic toxicity, which can be dangerous.
The nurse should notify the provider immediately for assessment and possible adjustment or discontinuation.
Simply increasing fiber/fluids (A) or taking with meals (D) does not address toxicity. Reassurance alone (C) is unsafe.
A 38-year-old patient complains that their coworker is always “hostile and unfair,” but during a group session, the patient admits feeling angry about being reprimanded at work and snaps at a classmate for a minor mistake.
Which defense mechanisms are demonstrated?
A. Rationalization and denial
B. Projection and displacement
C. Undoing and sublimation
D. Repression and denial
Answer: B
Projection: Patient attributes their own hostile feelings to the coworker.
Displacement: Redirecting anger from the supervisor to the classmate, a safer target.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure
disorder. Which statement indicates the client understands the discharge teaching
concerning this medication?
A. "I will brush my teeth after every meal."
B. "I will check my Dilantin level daily."
C. "My urine will turn orange while on Dilantin."
D. "I won't have any seizures while on this medication."
A.
Thorough oral hygiene after each
meal, gum massage, daily flossing,
and regular dental care are essential
to prevent or control gingival
hyperplasia, which is a common
occurrence in clients taking
Dilantin.
A nurse is caring for a client who sustained a severe traumatic brain injury after a motor vehicle accident. The client’s current vital signs are:
BP: 180/60 mmHg
HR: 48 bpm
RR: 8/min, irregular
The client, who was previously responsive, is now difficult to arouse and shows decerebrate posturing.
Which action should the nurse take first?
A. Administer IV mannitol as prescribed.
B. Increase the head of the bed to 30 degrees and maintain neutral neck alignment.
C. Notify the healthcare provider immediately.
D. Check the client’s pupillary response and Glasgow Coma Scale score.
Answer: B.
The client’s vital signs (↑ systolic BP, ↓ HR, irregular respirations) reflect Cushing’s triad, a late and life-threatening sign of increased intracranial pressure (ICP) and impending brain herniation.
The first action is to decrease ICP immediately — raising the head of bed 30° and keeping the neck midline promotes venous drainage from the brain and can temporarily relieve pressure while you prepare for further interventions.
After positioning:
Then notify the provider (C) and expect orders for osmotic diuretics (mannitol) and possible intubation or hyperventilation.
Checking pupils (D) provides assessment data but does not treat the cause — you need to act before deterioration worsens.
A nurse cares for a client with bipolar mania who has not slept or eaten in three days and is constantly running around the unit. Which nursing diagnosis takes priority?
A. Risk for injury related to hyperactivity
B. Disturbed thought processes related to flight of ideas
C. Imbalanced nutrition: less than body requirements
D. Sleep deprivation related to increased energy
Answer: A
The immediate risk is physical exhaustion and injury due to hyperactivity.
A PTSD client becomes panicked during a fire-drill alarm. Arrange the nurse’s actions in order:
1️⃣ Administer PRN lorazepam.
2️⃣ Move the client to a quiet environment.
3️⃣ Reassure safety and use grounding techniques.
4️⃣ Notify provider of the episode.
Correct order: 2 → 3 → 1 → 4.
2: Remove trigger.
3: Calm and orient.
1: Medication if non-pharmacologic methods fail.
4: Report and document afterward.
A 29-year-old woman has been admitted to multiple hospitals in the past year for recurrent episodes of severe abdominal pain and unexplained bleeding. Extensive testing has revealed no physiological abnormalities. The client eagerly discusses her previous “rare diseases”, is very knowledgeable about medical terminology, and becomes defensive when staff suggest psychiatric evaluation. The nurse overhears her later injecting herself with insulin obtained from another patient’s supply.
Which nursing interpretation best explains this behavior?
A. The client is seeking secondary gain, such as money or avoiding responsibilities.
B. The client is consciously producing symptoms to assume the sick role and receive attention and care.
C. The client is experiencing somatic symptom disorder and genuinely believes she is ill.
D. The client’s symptoms are caused by a delusional belief about having multiple diseases.
Answer – B
In Factitious Disorder (Munchausen Syndrome), the individual consciously fabricates or induces symptoms to assume the sick role and gain attention or nurturance — without external incentives.
(A) describes malingering, where motivation is external (e.g., avoiding work, financial gain).
(C) describes somatic symptom disorder, where symptoms are unconscious and believed to be real.
(D) describes delusional disorder, which involves fixed false beliefs, not intentional symptom creation.
A nurse is educating nursing students about TB precautions. Which statement demonstrates correct understanding?
A. “Clients with latent TB require airborne precautions.”
B. “Clients with latent TB are contagious only if coughing.”
C. “Only clients with active TB and positive sputum cultures are contagious.”
D. “Once TB medication begins, airborne precautions can be stopped immediately.”
Answer: C.
Active, pulmonary TB = contagious; latent TB = not contagious at all. Precautions continue until 3 negative sputum cultures.
A client with OCD and depression is prescribed fluoxetine. The client reports new restlessness, sweating, and confusion. Which action should the nurse take first?
A. Reassure the client that this is a temporary side effect
B. Notify the provider immediately
C. Administer PRN lorazepam
D. Document findings and continue to monitor
Answer: B
Symptoms suggest serotonin syndrome — a medical emergency. Must stop serotonergic agents and report to provider immediately.
A 34-year-old patient has been taking sertraline for major depressive disorder for 6 months. The patient says, “I feel fine now; I think I can stop taking it today.”
Which explanation best describes why abrupt discontinuation of SSRIs is not recommended?
A. Stopping suddenly can cause permanent serotonin receptor damage.
B. Abrupt cessation can lead to discontinuation syndrome, including dizziness, flu-like symptoms, insomnia, and irritability.
C. SSRIs have a high risk of addiction similar to benzodiazepines, so stopping suddenly causes withdrawal seizures.
D. Abrupt discontinuation will immediately reverse all therapeutic benefits, causing rapid relapse of depression.
B.
Abrupt discontinuation of SSRIs can lead to discontinuation syndrome, which may include dizziness, headache, nausea, flu-like symptoms, insomnia, irritability, and “electric shock” sensations.
SSRIs do not cause permanent serotonin receptor damage (A).
They are not addictive like benzodiazepines, so seizures are not typical with abrupt stopping (C).
Stopping abruptly does not instantly reverse therapeutic benefits (D), but it can cause uncomfortable withdrawal-like symptoms and potential relapse.
A patient with depression missed their therapy appointment and says:
“My therapist never calls me on time anyway”
Eats a chocolate bar despite dietary restrictions, claiming “I don’t have a sugar problem”
Later yells at the roommate for being messy
Which defense mechanisms are present? (Select all that apply)
A. Projection
B. Rationalization
C. Denial
D. Displacement
Answer: A, B, C, D
Projection: Blaming the therapist for being late.
Rationalization: Excusing missed therapy.
Denial: Refusing to acknowledge dietary consequences.
Displacement: Redirecting anger toward roommate.