PHARM
A client with anxiety is prescribed lorazepam. Which instruction should the nurse include during medication teaching?
A. Take the medication every morning with food
B. Avoid operating heavy machinery
C. Discontinue the medication if you feel sleepy
D. Skip the dose if feeling nervous
Correct Answer: B
Rationale: Lorazepam is a benzodiazepine and causes sedation. Safety precautions like avoiding heavy machinery should be taught.
Which statement best reflects a core concept in the Foundations of Mental Health Nursing?
A. Mental illness is a result of poor parenting.
B. Mental health and mental illness exist on a continuum.
C. People with mental illness cannot function independently.
D. Mental health disorders are always lifelong.
Correct Answer: B
Rationale: Mental health is not all-or-nothing; individuals move along a continuum based on functioning and stress levels.
A client recently lost their job and reports feeling “numb” and withdrawn. This response is most consistent with which stage of the grieving process?
A. Bargaining
B. Anger
C. Denial
D. Depression
Correct Answer: C
Rationale: Emotional numbness and shock are common in the initial denial phase of grief.
A client with major depressive disorder has been prescribed sertraline. Which client statement indicates a need for further teaching?
A. “I may not feel better for a few weeks.”
B. “I should take this medication every day.”
C. “I can stop the medication when I feel better.”
D. “I should report any suicidal thoughts to my provider.”
Correct Answer: C
Rationale: Clients should not stop antidepressants abruptly, even if symptoms improve.
A client with post-traumatic stress disorder (PTSD) reports nightmares and flashbacks. Which intervention is most appropriate for initial management?
A. Encourage the client to avoid discussing the trauma
B. Administer benzodiazepines routinely
C. Provide a calm, structured environment and grounding techniques
D. Suggest watching calming TV before bed
Correct Answer: C
Rationale: A structured, safe environment and grounding techniques help reduce anxiety and reorientation during flashbacks.
A client taking clozapine reports fever and sore throat. What is the nurse’s priority action?
A. Administer acetaminophen
B. Continue the medication and monitor
C. Notify the provider and obtain a CBC
D. Offer fluids and rest
Correct Answer: C
Rationale: Clozapine may cause agranulocytosis. A CBC must be drawn immediately.
According to psychosocial theories, what is the primary defense mechanism seen in patients with unresolved early developmental conflict?
A. Denial
B. Displacement
C. Regression
D. Projection
Correct Answer: C
Rationale: Regression is a return to an earlier stage of development and is often seen when clients face stress or conflict.
Which action by the nurse is most effective when a client displays escalating aggression on the unit?
A. Stand directly in front of the client and assert control
B. Call security and leave the room immediately
C. Use a calm, firm voice and set clear limits
D. Challenge the client's irrational beliefs
Correct Answer: C
Rationale: De-escalation involves calm communication and limit-setting to maintain safety.
Which behavior is most consistent with manic phase of bipolar disorder?
A. Avoidance of social interaction
B. Speaking slowly with long pauses
C. Grandiose ideas and decreased sleep
D. Excessive fear and panic attacks
Correct Answer: C
Rationale: Mania is characterized by inflated self-esteem, reduced need for sleep, and pressured speech.
Which statement by the caregiver of a child with autism spectrum disorder indicates a need for further teaching?
A. “I avoid making eye contact with them.”
B. “I use short, simple instructions.”
C. “I give them time to respond.”
D. “I maintain a predictable routine.”
Correct Answer: A
Rationale: While many children with autism avoid eye contact, caregivers should not avoid it themselves—modeling is important.
A client is prescribed fluoxetine for depression. Which reported symptom requires immediate attention?
A. Dry mouth
B. Nausea
C. Sexual dysfunction
Correct Answer: D
Rationale: Antidepressants can increase suicide risk during the early phase due to energy returning before mood improves.
A nurse is assessing a patient using the Mental Status Examination (MSE). Which of the following is an example of assessing the “thought process”?
A. “I feel sad most of the time.”
B. “I think I’m being followed by aliens.”
C. “My thoughts jump from topic to topic rapidly.”
D. “I have trouble remembering things.”
Correct Answer: C
Rationale: “Thought process” refers to the flow of ideas, and rapid shifting is an example of flight of ideas.
A client experiencing generalized anxiety disorder (GAD) is prescribed buspirone. What teaching should the nurse include?
A. “This medication works immediately to relieve anxiety.”
B. “Avoid alcohol while taking this medication.”
C. “Take this medication only when symptoms occur.”
D. “It may cause sedation and should be taken at bedtime.”
Correct Answer: B
Rationale: Buspirone is non-sedating and must be taken consistently. Alcohol should be avoided due to CNS effects.
Which priority nursing action applies when caring for a client with obsessive-compulsive disorder (OCD) who washes their hands every 15 minutes?
A. Prevent the behavior immediately
B. Encourage the client to ignore the urge
C. Allow the ritual but set limits
D. Distract the client with group activities
Correct Answer: C
Rationale: Rituals may need to be initially supported but gradually limited as part of treatment.
A nurse is teaching a client newly diagnosed with mild Alzheimer’s disease about safety. Which teaching is most important?
A. “Encourage daily walks alone to promote independence.”
B. “Install locks and alarms on exit doors.”
C. “Rotate caregivers frequently to prevent dependence.”
D. “Avoid structured routines to increase flexibility.”
Correct Answer: B
Rationale: Clients with cognitive decline are at risk for wandering. Home safety modifications are critical early on.
A client being treated for bipolar disorder with lithium shows slurred speech, unsteady gait, and confusion. What is the nurse’s priority intervention?
Hold the lithium dose and notify the provider—these are signs of lithium toxicity that require immediate medical attention.
A client is admitted involuntarily after expressing intent to harm a neighbor. The nurse explains the client’s rights. What legal principle justifies the client’s detention, and what rights must still be upheld?
The client is detained under the principle of duty to protect. Despite involuntary admission, the client retains rights such as informed consent, access to treatment, and the right to refuse medications (unless legally overridden).
A nurse is assessing a client with a history of substance use disorder who is being treated for anxiety. The client is requesting alprazolam. What concerns should the nurse raise, and what alternative treatments might be more appropriate?
Benzodiazepines like alprazolam carry a high risk of dependency and are contraindicated in clients with substance use disorders. The nurse should advocate for safer alternatives like SSRIs, SNRIs, or buspirone, and suggest CBT as a non-pharmacologic option.
A client with schizophrenia is experiencing auditory hallucinations and states, “They’re telling me I’m worthless.” How should the nurse respond therapeutically, and what is the clinical rationale for this response?
The nurse should respond with validation of the experience without reinforcing the hallucination, such as:
“I understand that the voices are real to you, but I don’t hear them. Let’s talk about how you’re feeling.”
This builds trust, maintains reality orientation, and helps reduce anxiety associated with hallucinations.
A nurse is assessing a child who presents with frequent bruises, withdrawn behavior, and fear of physical contact. The parent interrupts the interview and insists on staying in the room. What is the nurse’s priority, and what steps should be taken?
The nurse must ensure a private assessment and report suspicions of child abuse according to facility protocol. The child should be assessed for safety, and findings documented clearly and objectively.
A client taking risperidone for schizophrenia presents with a high fever, muscle rigidity, and altered mental status. What condition does the nurse suspect, and what is the appropriate action?
The nurse suspects Neuroleptic Malignant Syndrome (NMS). The appropriate action is to stop the medication immediately and contact the provider for emergency care.
A nurse is working in an outpatient psychiatric setting and has been seeing the same client for several months. The client begins expressing romantic interest and asks the nurse to meet outside of sessions. What is the nurse’s most appropriate response, and what principle of therapeutic communication does this reflect?
The nurse should reaffirm professional boundaries and explain that a personal relationship is not appropriate within the therapeutic context. This reflects the principle of maintaining therapeutic boundaries to protect the integrity of the nurse-client relationship and prevent role confusion or harm.
A client with somatic symptom disorder frequently visits the clinic with vague complaints and requests multiple diagnostic tests. How should the nurse respond therapeutically while minimizing reinforcement of somatic behavior?
The nurse should acknowledge the client’s emotional distress without focusing on physical symptoms. For example:
“I can see that you’re really struggling right now. Let’s talk more about what’s been going on in your life lately.”
This supports emotional processing while avoiding excessive medical reinforcement.
During a home visit, a nurse observes a client with Alzheimer’s disease living with a caregiver. The client has bruises in various stages of healing and appears fearful. What are the nurse’s legal and ethical obligations, and what is the priority action?
The nurse is a mandatory reporter of elder abuse and must report the suspicion to adult protective services. The priority action is to ensure the client’s immediate safety and initiate appropriate interventions while following agency policy and legal guidelines.
A college student survivor of sexual assault presents to the emergency department in distress. What are the nurse’s immediate priorities and long-term care considerations?
Immediate priorities include providing emotional support, ensuring physical safety, and following protocols for forensic evidence collection (with consent). Long-term care includes referrals for counseling, trauma-informed follow-up, and respecting autonomy in decision-making.