Foundations & Therapeutic Tools
A client with schizophrenia says to the nurse, "The voices are telling me that I am worthless." What is the nurse's best therapeutic response?
A. "The voices are not real."
B. "What are the voices saying to you?"
C. "You should ignore the voices."
D. "Why do you think the voices are talking to you?"
Answer: B. "What are the voices saying to you?"
Rationale:
The nurse acknowledges the client's experience without reinforcing the hallucination and assesses for content, especially if the voices are command hallucinations.
The PN is caring for a client with major depressive disorder who was started on an SSRI (sertraline) 7 days ago. The client states, "I feel just as terrible as when I came in. These pills aren't working." Which is the best response?
A) "I will notify your provider immediately to increase the dose."
B) "SSRIs typically take 4-6 weeks to reach full effect. Let's keep monitoring your symptoms."
C) "You must not be taking the medication as prescribed. Have you been skipping doses?"
D) "Maybe this isn't the right medication for you. We should ask for something different."
Correct Answer: B
Rationale: SSRIs have a delayed onset of action (4-6 weeks). The nurse provides realistic education to prevent premature discontinuation.
A nurse is caring for a client experiencing a crisis after losing their home in a fire. Which nursing action is the priority?
A. Encourage the client to discuss childhood experiences
B. Help the client identify immediate needs and available resources
C. Teach stress-management techniques for future use
D. Encourage the client to journal feelings daily
Answer: B
Rationale: During a crisis, the priority is addressing immediate safety and basic needs. Helping the client obtain shelter, food, support, and resources promotes stabilization before long-term coping strategies are addressed.
A client with Bipolar I Disorder is admitted during a manic episode. Which behavior would the nurse expect?
A. Slow speech and withdrawal
B. Excessive energy and decreased need for sleep
C. Feelings of hopelessness and guilt
D. Flat affect and lack of motivation
Answer: B
Rationale: Mania is characterized by excessive energy, euphoria, hyperactivity, rapid speech, impulsivity, and a decreased need for sleep. The other findings are more consistent with depression.
A client with major depressive disorder says, "Life isn't worth living anymore." What is the nurse's priority response?
A. "Why do you feel that way?"
B. "Things will get better soon."
C. "Are you thinking about harming yourself?"
D. "You should focus on positive things."
Answer: C
Rationale: When a client expresses hopelessness, the nurse should directly assess for suicidal thoughts. Asking about suicide does not increase the risk and is the priority action.
A client diagnosed with depression says to the nurse, "Nothing matters anymore. Everyone would be better off without me."
What is the nurse's best response?
A. "Your family loves you and would miss you."
B. "Why do you feel that way?"
C. "Are you thinking about hurting yourself?"
D. "You shouldn't talk like that."
Correct Answer: C. "Are you thinking about hurting yourself?"
Rationale: The client is expressing hopelessness, a major warning sign for suicide. The nurse must directly assess for suicidal ideation. Asking about suicide does not increase the risk; it helps identify danger and protect the client.
A client in the manic phase of bipolar disorder is pacing rapidly, talking loudly, and has not slept or eaten for two days. The client says, "I'm going to start five new businesses today and run a marathon!" Which is the priority nursing action?
A) Encourage the client to write down business ideas in a journal.
B) Offer high-calorie finger foods and fluids while the client paces.
C) Tell the client to sit still and stop being unrealistic.
D) Restrain the client to prevent exhaustion and dehydration.
Correct Answer: B
Rationale: In acute mania, the priority is preventing malnutrition and dehydration. Finger foods allow the client to keep moving. Restraint is not indicated unless there is imminent danger.
A client who spends excessive time gambling states, "I can win back all the money I lost if I keep playing." Which response by the nurse is most appropriate?
A. "You should stop gambling immediately."
B. "Tell me more about what makes you believe that."
C. "You are making poor financial decisions."
D. "Your family is probably frustrated with you."
Answer: B
Rationale: Therapeutic communication encourages exploration of thoughts and feelings without judgment. Gambling disorder often involves distorted thinking and unrealistic beliefs about winning.
A client taking lithium reports nausea, diarrhea, and muscle weakness. What is the nurse's priority action?
A. Encourage the client to take the next dose with food
B. Document the findings as expected side effects
C. Hold the medication and notify the healthcare provider
D. Instruct the client to increase caffeine intake
Answer: C
Rationale: Nausea, diarrhea, and muscle weakness are early signs of lithium toxicity. The medication should be held and the healthcare provider notified immediately.
A client with generalized anxiety disorder is experiencing severe anxiety. Which nursing intervention is most appropriate?
A. Provide detailed teaching about medications
B. Encourage participation in a large group activity
C. Remain with the client and speak calmly
D. Ask the client to make important decisions
Answer: C
Rationale: During severe anxiety, the client's ability to concentrate is reduced. A calm presence and simple communication help decrease anxiety and promote safety.
The PN is caring for a client with severe major depressive disorder. The client states, “There’s no point in going on. I’m worthless, and everything is hopeless.” Which response demonstrates empathy?
A) “I know how you feel. I went through a terrible divorce and felt just like that.”
B) “You have so much to live for – your children, your health. Don’t give up.”
C) “It sounds like you are feeling hopeless and worthless. That pain must be exhausting.”
D) “Have you told your doctor about these feelings? He can adjust your medication.”
Correct Answer: C
Rationale: Reflects the client’s feelings (empathy) without minimizing or providing false reassurance.
A client with schizophrenia sits motionless for hours, makes no eye contact, speaks only when spoken to with one-word answers, and shows no interest in hygiene. Which set of symptoms is the client exhibiting?
A) Positive symptoms
B) Negative symptoms
C) Cognitive symptoms
D) Affective symptoms
Correct Answer: B
Rationale: Negative symptoms include flat affect, alogia (few words), avolition (no motivation), and social withdrawal. Positive symptoms are hallucinations/delusions.
A nurse assesses a client after a natural disaster. Which finding requires immediate intervention?
A. Difficulty sleeping
B. Expresses sadness about property loss
C. States, "I wish I had died too."
D. Reports decreased appetite
Answer: C
Rationale: Statements indicating suicidal thoughts require immediate assessment and intervention. Safety is always the highest priority in mental health nursing.
Which laboratory value indicates a therapeutic lithium level?
A. 0.2 mEq/L
B. 0.6 mEq/L
C. 2.0 mEq/L
D. 2.5 mEq/L
Answer: B
Rationale: The therapeutic lithium range is generally 0.6–1.2 mEq/L. Levels above 1.5 mEq/L may indicate toxicity.
A client diagnosed with schizophrenia states, "The TV news anchor is sending me secret messages." The nurse recognizes this as:
A. Hallucination
B. Delusion
C. Ideas of reference
D. Echolalia
Answer: C
Rationale: Ideas of reference occur when a client believes unrelated events or messages are directed specifically at them.
A client with schizophrenia is withdrawn and sitting alone. The PN sits nearby without speaking for 5 minutes. The client then says quietly, “The voices are loud today.” The PN remains silent but nods gently. The client adds, “They tell me I’m bad.” Which rationale best supports the PN’s use of silence?
A) Silence forces the client to break the ice and take responsibility for conversation.
B) Silence gives the client control over the pace and content of the interaction.
C) Silence is used when the nurse does not know what to say to the client.
D) Silence is the best way to avoid reinforcing the client’s delusions or hallucinations.
Correct Answer: B
Rationale: Therapeutic silence empowers the client to lead the interaction at their own pace.
A veteran with PTSD startles violently when a food tray drops on the floor. The client then begins sweating, hyperventilating, and yells, "Get down! Incoming!" Which is the best immediate response by the PN?
A) "You are in the hospital. No one is shooting. You are safe now."
B) "Stop yelling. You are scaring the other clients."
C) "I'll give you a PRN sedative and leave you alone to calm down."
D) "Tell me more about what you're seeing right now."
Correct Answer: A
Rationale: During a flashback/hyperarousal, the nurse gently reorients the client to reality (time, place, safety). Do not argue or demand that they stop; do not explore trauma during acute distress.
The nurse is caring for an older adult living alone. Which finding is most suggestive of elder abuse?
A. The client has arthritis and limited mobility.
B. The client reports difficulty sleeping.
C. The client has unexplained bruises in various stages of healing.
D. The client receives meals from a community program.
Answer: C
Rationale: Unexplained injuries, especially bruises at different healing stages, are a major warning sign of physical abuse and should be reported according to facility policy.
A client with mania is constantly moving and unable to sit still during meals. Which intervention is most appropriate?
A. Offer high-calorie finger foods and fluids
B. Restrict food intake until behavior improves
C. Encourage group dining with other clients
D. Provide large meals three times daily
Answer: A
Rationale: Clients experiencing mania often cannot sit long enough to eat complete meals. High-calorie finger foods and frequent fluids help maintain nutrition and hydration.
A client says, "I hear voices telling me to hurt myself." What is the nurse's priority action?
A. Ask what the voices are saying
B. Tell the client the voices are not real
C. Leave the client alone to rest
D. Change the subject
Answer: A
Rationale: Command hallucinations can lead to self-harm or violence. The nurse must assess the content of the hallucinations and ensure safety.
The PN is assessing a newly admitted client with paranoid schizophrenia. The client states, "I know you're working for the government. Those cameras in the hallway are watching me." Which is the most therapeutic initial response?
A) "There are no cameras in the hallway. You are experiencing a delusion."
B) "That must feel very frightening. You are safe here. I am a nurse, not a government agent."
C) "Let's talk about something else. What did you have for breakfast?"
D) "Why do you think the government would be watching you?"
Correct Answer: B
Rationale: Validates the client's feeling (fear) without reinforcing the delusion and gently presents reality without arguing.
A client with alcohol use disorder has not had a drink for 24 hours. The PN notes tremors, sweating, a heart rate of 118, and blood pressure of 150/95. The client is becoming confused and disoriented. Which complication is the client most likely developing?
A) Wernicke's encephalopathy
B) Korsakoff syndrome
C) Delirium tremens (DTs)
D) Alcohol intoxication
Correct Answer: C
Rationale: Delirium tremens occurs 24-72 hours after the last drink and includes autonomic instability (tachycardia, hypertension), tremors, and confusion. DTs are a medical emergency.
A client diagnosed with internet gaming disorder states, "I haven't gone to work in three days because I can't stop playing." Which nursing assessment is most important?
A. Favorite video game
B. Sleep patterns and daily functioning
C. Childhood friendships
D. Preferred gaming device
Answer: B
Rationale: Behavioral addictions are identified by their negative impact on daily functioning, relationships, employment, and health. Assessing functioning and sleep is essential.
A nurse is teaching a client about lithium therapy. Which statement by the client indicates understanding?
A. "I should reduce my salt intake as much as possible."
B. "I should drink 2–3 liters of water daily unless otherwise instructed."
C. "I can stop taking lithium when I feel better."
D. "I should skip doses if I develop tremors."
Answer: B
Rationale: Adequate hydration helps prevent lithium toxicity. Sudden decreases in sodium or fluid intake can increase lithium levels and lead to toxicity.
A client with depression has been taking an antidepressant for 3 weeks. Which statement indicates improvement?
A. "I stay in bed all day."
B. "I attended a group activity today."
C. "I avoid talking to others."
D. "I have no interest in anything."
Answer: B
Rationale: Increased participation in activities and social interaction are signs that depressive symptoms are improving.