The interactive test above draws from this bank in random order. Every question also has its own page with the full explanation.
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Which is an example of therapeutic communication?
- 'You shouldn't feel that way'
- 'Don't worry, everything will be fine'
- 'Tell me more about what you are experiencing' ✓
- 'I know exactly how you feel'
Therapeutic communication encourages clients to express thoughts and feelings, helps them work through issues, and supports the nurse-client relationship. Key techniques: (1) Open-ended questions/statements — invite elaboration ('Tell me more...', 'How are you feeling about...?'); (2) Active listeni… Full explanation →
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A client states 'I just can't take this anymore. I want to end it all.' What is the nurse's most appropriate initial response?
- 'Don't say that — you have so much to live for'
- 'Things will get better with time'
- 'Are you thinking of hurting yourself or ending your life?' ✓
- 'Let me change the subject'
When suicidal ideation is suggested or stated, the nurse must directly assess for suicide intent — this is the priority intervention. Asking about suicide does NOT plant the idea or increase risk; on the contrary, direct assessment is essential and may relieve the client. Assessment questions: (1) '… Full explanation →
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What are common symptoms of major depressive disorder?
- Hallucinations only
- Depressed mood, anhedonia (loss of interest), changes in appetite or weight, sleep disturbance, fatigue, psychomotor agitation or retardation, feelings of worthlessness or guilt, decreased concentration, thoughts of death or suicide — 5+ symptoms present for 2+ weeks ✓
- Increased energy
- Manic episodes
Major Depressive Disorder (DSM-5 criteria): five or more of the following symptoms present during the same 2-week period and representing a change from previous functioning. At least one symptom must be depressed mood or anhedonia. Symptoms: (1) Depressed mood most of the day, nearly every day — sad… Full explanation →
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What are characteristic features of bipolar disorder?
- Identical to depression
- Constant happiness
- Only depression
- Alternating episodes of mania (or hypomania) and depression — manic episodes feature elevated/irritable mood, increased energy, decreased sleep need, grandiosity, racing thoughts, pressured speech, distractibility, impulsivity ✓
Bipolar disorder involves episodes of mood elevation and depression. Mania (Bipolar I) — duration ≥7 days OR severe enough for hospitalization. Criteria: distinct period of abnormally elevated, expansive, or irritable mood AND increased goal-directed activity/energy; plus 3+ of (or 4+ if irritable):… Full explanation →
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What are the major features of schizophrenia?
- Mood swings only
- Depression alone
- Positive symptoms (hallucinations, delusions, disorganized speech/behavior) and negative symptoms (affective flattening, alogia, avolition, anhedonia, asociality), with significant functional impairment, lasting 6+ months ✓
- Anxiety only
Schizophrenia (DSM-5): 2+ symptoms present for significant portion of 1 month (or less if treated successfully): (1) Delusions — fixed false beliefs (persecutory, grandiose, somatic, religious, referential — believing TV is talking to you); (2) Hallucinations — false perceptions in any sense; audito… Full explanation →
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What are the symptoms of an anxiety attack/panic attack?
- Only mild worry
- Hallucinations only
- Sudden, intense fear/discomfort with multiple physical symptoms: palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, paresthesias, hot/cold flashes, fear of dying or losing control — usually peaks in 10 minutes ✓
- Slow gradual onset
Panic Attack: a discrete period of intense fear or discomfort with abrupt onset, peaking within minutes, including 4+ symptoms: (1) Palpitations, pounding heart, or accelerated heart rate; (2) Sweating; (3) Trembling or shaking; (4) Shortness of breath or smothering sensation; (5) Choking sensation;… Full explanation →
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What are the five stages of grief described by Elisabeth Kübler-Ross?
- Sad, mad, glad
- Three stages only
- Hope, fear, peace
- Denial, Anger, Bargaining, Depression, Acceptance — not a linear progression; stages may be revisited, skipped, or occur in different order ✓
Kübler-Ross's five stages of grief (developed from observing dying patients in 'On Death and Dying,' 1969): (1) Denial — 'This can't be happening' — protects from initial shock; (2) Anger — 'Why me? It's not fair' — directed at self, others, healthcare team, God; (3) Bargaining — 'If only...' — atte… Full explanation →
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What is a 'crisis' in mental health, and what are the key principles of crisis intervention?
- Long-term therapy
- A state of psychological disequilibrium where usual coping methods fail to resolve a stressor; crisis intervention is short-term (4-6 weeks typical), focused, problem-solving, mobilizing resources, restoring function — not deep therapy ✓
- Any disagreement
- Just listening
A crisis is a state of disequilibrium caused by a stressor that overwhelms the person's usual coping abilities. Types of crisis: (1) Maturational/developmental — normal life transitions (marriage, parenthood, retirement) that overwhelm; (2) Situational — unexpected events (illness, loss, accident, d… Full explanation →
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What are the typical features of alcohol withdrawal?
- Only mild headache
- No physical symptoms
- Onset 6-24 hours after last drink; symptoms include tremors, anxiety, nausea, sweating, increased BP/HR, insomnia; severe withdrawal includes seizures (24-48 hours), hallucinations (visual common), and delirium tremens (DTs) at 48-96 hours — DTs can be fatal ✓
- Resolves in hours
Alcohol withdrawal occurs in people physically dependent on alcohol. Severity ranges from mild discomfort to life-threatening. Timeline: (1) 6-24 hours: minor withdrawal — tremors (especially hands), anxiety, headache, nausea/vomiting, sweating, increased pulse and blood pressure, insomnia, agitatio… Full explanation →
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What are the typical symptoms of opioid withdrawal?
- Identical to alcohol withdrawal
- Anxiety, restlessness, dilated pupils, muscle aches, diarrhea, nausea/vomiting, runny nose, tearing, yawning, sweating, chills, piloerection ('goosebumps'); unpleasant but not life-threatening in healthy adults ✓
- Life-threatening seizures
- No symptoms
Opioid withdrawal is uncomfortable but not life-threatening in healthy adults (unlike alcohol/benzodiazepine withdrawal). Symptoms: anxiety, restlessness, dysphoria; pupils dilated (mydriasis — opposite of intoxication which causes pinpoint pupils); muscle aches and bone pain; abdominal cramps, diar… Full explanation →
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What is the most effective response if a nurse suspects a colleague is impaired at work?
- Report concerns through proper channels — typically to charge nurse or supervisor; protects patients and the colleague who needs intervention; mandatory in many state nurse practice acts; impaired nurse programs offer recovery support ✓
- Wait for someone else
- Confront the colleague publicly
- Ignore it
Nurses have an ethical and (in most states) legal duty to report suspected impairment of colleagues. The behavior may be substance use, mental health issues, or medical conditions affecting function. Why report: (1) Patient safety — impaired nurses can harm patients through errors, missed observatio… Full explanation →
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What are healthy versus unhealthy coping mechanisms?
- Coping is unnecessary
- Healthy: exercise, social support, problem-solving, relaxation techniques, hobbies, professional help. Unhealthy: substance use, social isolation, denial, aggression, self-harm, overeating/restriction, excessive screen time, avoidance ✓
- All coping is unhealthy
- All coping is healthy
Coping mechanisms are strategies used to manage stress, emotions, and difficult situations. Healthy (adaptive) coping: (1) Problem-focused — addressing the stressor: planning, seeking information, taking action; (2) Emotion-focused (used when problem can't be changed) — acceptance, emotional support… Full explanation →
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What is 'cultural competence' in nursing care?
- The ability to deliver care that recognizes, respects, and accommodates the cultural beliefs, values, practices, and needs of patients from diverse backgrounds — without stereotyping; requires self-awareness, knowledge, skill, and ongoing learning ✓
- Only relevant for some patients
- Treating everyone identically
- Knowing one's own culture
Cultural competence is an essential nursing capability in increasingly diverse healthcare environments. Components: (1) Self-awareness — recognizing one's own cultural background, biases, and assumptions; (2) Cultural knowledge — understanding common health beliefs, practices, communication styles, … Full explanation →
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What is the appropriate approach to spiritual care in nursing?
- Pray with every patient
- Assess spiritual needs as part of holistic care; respect the patient's beliefs whether or not they match the nurse's; facilitate spiritual practices the patient values; refer to chaplaincy or the patient's clergy; do not impose one's own beliefs ✓
- Always avoid religious topics
- Promote nurse's religion
Spiritual care is part of holistic nursing — recognizing that spiritual well-being affects physical and mental health. Spirituality includes religious beliefs but extends beyond — meaning, purpose, connection, transcendence, values. Spiritual assessment: (1) Faith/Beliefs — what is important to you?… Full explanation →
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What is post-traumatic stress disorder (PTSD) and what are its key symptoms?
- Only physical injury
- Mental health disorder following exposure to actual or threatened death, serious injury, or sexual violence; symptoms include intrusion (flashbacks, nightmares), avoidance, negative alterations in cognition/mood, and arousal/reactivity — lasting >1 month ✓
- Brief sadness after stress
- Brief reaction
PTSD (DSM-5) develops in some individuals exposed to trauma — actual or threatened death, serious injury, or sexual violence. Exposure types: directly experiencing, witnessing, learning about (close family/friend), or repeated/extreme exposure (first responders). Symptoms persist >1 month and cause … Full explanation →
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A client with borderline personality disorder (BPD) alternates between telling one nurse 'You're the only one who understands me' and telling another 'She doesn't care about me at all.' This behavior pattern is called:
- Transference
- Projection
- Splitting — seeing people as all good or all bad without integration; a hallmark defense mechanism in BPD ✓
- Manipulation
SPLITTING is a primitive defense mechanism characteristic of BORDERLINE PERSONALITY DISORDER (BPD) in which the person cannot integrate the good and bad qualities of people (or themselves) and instead perceives them as either entirely good or entirely bad. In a clinical setting, splitting often mani… Full explanation →
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A client has been diagnosed with post-traumatic stress disorder (PTSD) following a motor vehicle accident. Which symptom cluster is MOST characteristic of PTSD?
- Persistent sadness and anhedonia only
- Grandiosity, decreased need for sleep, and racing thoughts
- Re-experiencing the trauma (flashbacks, nightmares), avoidance (of trauma reminders), negative cognitions/mood, and hyperarousal (exaggerated startle, hypervigilance, sleep disturbance) ✓
- Paranoid delusions and hallucinations
PTSD is a trauma- and stressor-related disorder defined by four symptom clusters (DSM-5), all present for more than 1 month following exposure to actual or threatened death, serious injury, or sexual violence: (1) RE-EXPERIENCING (INTRUSION): flashbacks (reliving the trauma as if it is happening now… Full explanation →
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A nurse responds to a client's tearful statement by saying, 'It sounds like you're feeling overwhelmed by everything that's happened.' This technique is called:
- False reassurance
- Reflection — restating the underlying feeling the client expressed to show understanding and invite further exploration ✓
- Closed questioning
- Giving advice
REFLECTION is a therapeutic communication technique in which the nurse communicates back the FEELING or CONTENT of what the client has expressed, demonstrating understanding and inviting the client to explore further. Two types: CONTENT REFLECTION — paraphrasing the facts or content ('So you're sayi… Full explanation →
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A client in alcohol withdrawal is assessed using the CIWA-Ar scale. Which score range indicates SEVERE withdrawal requiring close monitoring and aggressive pharmacological treatment?
- Score 0-9
- Score ≥15-20 (severe) — indicates high risk for withdrawal seizures and delirium tremens; requires IV benzodiazepines, intensive monitoring, and possible ICU-level care ✓
- Any score requires the same treatment
- Score 5-7
The CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL (CIWA-Ar) is a 10-item standardized scale used to assess alcohol withdrawal severity and guide treatment. CIWA-Ar ITEMS (each scored 0-7, except orientation which is 0-4): nausea/vomiting; tremor; paroxysmal sweats; anxiety; agitation; tactile… Full explanation →
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A nurse following the crisis intervention model responds to a client who reports their spouse just left them and they feel there is no reason to live. Which approach is CORRECT?
- Assess for suicidal ideation using direct questioning, implement safety measures as indicated, provide crisis support, and connect the client to additional resources — crisis intervention focuses on immediate stabilization, not long-term therapy ✓
- Tell the client to call back when they have calmed down
- Refer the client to a support group only
- Offer only general advice without safety assessment
CRISIS INTERVENTION is a short-term, active approach designed to help an individual in a crisis reach an acceptable level of functioning. A CRISIS is a temporary state of disequilibrium in which the person's usual coping mechanisms are insufficient for the situation. PHASES OF CRISIS INTERVENTION (R… Full explanation →
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A client with alcohol use disorder is in early recovery and asks the nurse about PAWS (Post-Acute Withdrawal Syndrome). What should the nurse explain?
- PAWS only occurs with opioid withdrawal
- PAWS is treated with benzodiazepines indefinitely
- PAWS does not exist — all withdrawal symptoms resolve within a week
- PAWS involves prolonged neurological symptoms (anxiety, sleep disturbance, mood instability, cognitive difficulties, reduced stress tolerance) that can persist for weeks to months after acute withdrawal resolves — understanding PAWS helps clients recognize it and not mistake it for relapse ✓
POST-ACUTE WITHDRAWAL SYNDROME (PAWS) — also called protracted withdrawal — is a second phase of withdrawal symptoms that emerge after the acute withdrawal phase resolves. CLINICAL PRESENTATION for alcohol (and other CNS depressants): Anxiety and irritability; sleep disturbances (insomnia, vivid dre… Full explanation →
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A nurse using motivational interviewing (MI) to help a client who is ambivalent about starting exercise for their heart disease. Which MI technique is the nurse using by saying, 'On one hand you're worried about your heart, and on the other hand exercise feels overwhelming. That's a real tension.'?
- Confrontation
- Reflective listening with double-sided reflection — acknowledging both sides of the client's ambivalence without judgment, which is the core technique of MI for building intrinsic motivation ✓
- Advice-giving
- Closed questioning
MOTIVATIONAL INTERVIEWING (MI) is an evidence-based, client-centered communication approach for facilitating behavior change in people who are ambivalent. CORE PRINCIPLES (RULE): Roll with Resistance; Understand the client's perspective; Listen with empathy; Empower the client. The FOUR PROCESSES: E… Full explanation →
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A client is admitted with first-episode psychosis. Which finding does NOT belong to the positive symptoms of schizophrenia?
- Social withdrawal, flat affect, and poverty of speech — these are NEGATIVE symptoms (absence of normal function), not positive (excess/distorted function) ✓
- Delusions of grandeur
- Auditory hallucinations
- Disorganized speech and behavior
SCHIZOPHRENIA SYMPTOM CLASSIFICATION — POSITIVE vs NEGATIVE SYMPTOMS: POSITIVE SYMPTOMS (presence of abnormal experiences not normally present): HALLUCINATIONS — false sensory perceptions; auditory most common in schizophrenia (hearing voices, often commenting, criticizing, or commanding); can be vi… Full explanation →
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A client's family asks if their loved one who is actively dying appears to be in pain. The client is unresponsive. What pain assessment approach should the nurse use?
- Unable to assess pain in unresponsive clients
- Only assess for pain if the patient is moving
- Use a behavioral pain observation scale (such as CPOT — Critical Pain Observation Tool — or PAINAD for dementia patients); observe for furrowed brow, grimacing, guarding, clenched teeth, rigid body, vocalizations; treat suspected pain proactively ✓
- Ask family if they think the patient is in pain and follow their answer
PAIN ASSESSMENT IN UNRESPONSIVE OR NON-VERBAL PATIENTS requires observational behavioral tools. The inability to self-report pain does NOT mean pain is absent — it means the nurse must observe for behavioral indicators. BEHAVIORAL PAIN SCALES FOR NON-VERBAL PATIENTS: CPOT (Critical-Pain Observation … Full explanation →
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A nurse is completing discharge teaching and the client says, 'I understand.' How should the nurse verify that understanding?
- Give the client a written handout and note it was provided
- Ask yes/no questions: 'Do you understand the diet?'
- Accept the statement and document 'client verbalized understanding'
- Use the teach-back method — ask the client to explain in their own words what they understand; 'Can you show me how you'll take your medication?' or 'What would you do if you noticed these warning signs?' — patient-demonstrated understanding is far more reliable than their self-report ✓
THE TEACH-BACK METHOD (also called the 'Show Me' method or Closing the Loop) is the evidence-based gold standard for verifying patient understanding of health education. WHY 'I UNDERSTAND' IS INSUFFICIENT: Studies show patients retain only 40-80% of what they are told; of what they retain, approxima… Full explanation →
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A client comes to the emergency department after disclosing suicidal ideation to a friend. The nurse's FIRST priority is:
- Administer sedation
- Assess the level of risk — determine whether the client has a plan, a method, and intent; this structures the immediate safety response and level of care needed ✓
- Call a psychiatrist
- Begin discharge paperwork
INITIAL SUICIDE RISK ASSESSMENT is the first priority because it determines the immediate safety response. ELEMENTS OF ASSESSMENT: IDEATION: Passive ('I wish I were dead') vs. active ('I am planning to kill myself'); PLAN: Specificity of plan (vague vs. specific date, method, location); METHOD: Avai… Full explanation →
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A dying client's family tells the nurse: 'We haven't told Mom she's dying — we don't want to upset her. Please don't tell her either.' How should the nurse respond?
- Agree to keep it secret from the client
- Acknowledge the family's love and protective intent; explain that the client has the ethical and legal right to information about their own health condition — the nurse cannot ethically deceive the client; offer to facilitate a family meeting with the palliative care team to address everyone's needs ✓
- Tell the client immediately without any preparation
- Side with the family to avoid conflict
TRUTH-TELLING AND PATIENT AUTONOMY: Clients have the ethical and legal right to information about their own health condition (autonomy). Withholding information from a competent client at the family's request violates this right and the nurse's ethical duty of veracity (truthfulness). CULTURAL CONTE… Full explanation →
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A client says: 'My doctor never explains anything to me. I don't understand what's happening.' The nurse's BEST response is:
- 'I'll tell the doctor to explain better.'
- 'Would you like me to arrange a patient advocate?'
- 'What specifically has been confusing or unclear for you? Let me help you understand what I can, and we can identify what questions you want to ask your doctor.' ✓
- 'Your doctor is very busy. I'm sure they explained it.'
THERAPEUTIC COMMUNICATION for expressed confusion: The best response: (1) VALIDATES the experience without dismissing or defending the physician; (2) EXPLORES the specific concern ('What specifically has been confusing') — this opens productive conversation rather than making assumptions; (3) OFFERS… Full explanation →
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A client with schizophrenia tells the nurse: 'The government has planted a device in my spine to monitor my thoughts.' What type of delusion is this?
- Somatic
- Erotomanic
- Persecutory/paranoid — the belief that an external force is controlling, monitoring, or persecuting the client; this is the most common type of delusion in schizophrenia ✓
- Grandiose
TYPES OF DELUSIONS: PERSECUTORY (most common in schizophrenia): Belief that someone or something is spying on, persecuting, or plotting against the client ('the government is monitoring me', 'my food is poisoned', 'I'm being followed'); GRANDIOSE: Belief that the client has special powers, status, o… Full explanation →
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A client who was just told they have cancer says: 'You must have the wrong chart. I was just at my annual physical last month and everything was fine.' Which defense mechanism is this?
- Sublimation
- Suppression
- Rationalization
- Denial — the client is refusing to accept the reality of the diagnosis; denial is often the first response to catastrophic news and is a normal, potentially adaptive initial defense mechanism that allows gradual processing ✓
DENIAL as initial response to catastrophic news is psychologically normal and may be adaptive. CHARACTERISTICS: Client rejects reality of the diagnosis or situation; may insist there is a mistake; may seek a second opinion (which can be healthy if not excessive); may continue discussing future plans… Full explanation →
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A client is admitted for alcohol withdrawal. Which symptom indicates the MOST life-threatening progression of withdrawal?
- Nausea and vomiting
- Delirium tremens (DTs) — characterised by confusion, agitation, hallucinations, hyperthermia, and autonomic instability (tachycardia, hypertension, diaphoresis); can progress to seizures and death if untreated ✓
- Insomnia and irritability
- Mild tremors
ALCOHOL WITHDRAWAL PROGRESSION: MILD (6-12 hours): Tremors, anxiety, nausea, diaphoresis, palpitations; MODERATE (12-48 hours): Same plus headache, vomiting, transient hallucinations (often visual/auditory), seizures (peak 24-48 hours); SEVERE — DELIRIUM TREMENS (48-96 hours): Life-threatening; diso… Full explanation →
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An elderly client tells the nurse: 'I have made peace with my life. I am ready to go.' According to Erikson's theory, which stage is reflected?
- Industry vs. Inferiority
- Generativity vs. Stagnation
- Identity vs. Role Confusion
- Ego Integrity vs. Despair — the final stage of Erikson's psychosocial development (late adulthood); successful resolution is ego integrity: the sense of having lived a meaningful, purposeful life; unsuccessful resolution is despair: regret, bitterness, and fear of death ✓
ERIKSON'S STAGES OF PSYCHOSOCIAL DEVELOPMENT — LATE ADULTHOOD (65+): STAGE: Ego Integrity vs. Despair; TASK: Reflect on life's meaning, accept one's life as it was lived, and face death with equanimity; SUCCESS (Ego Integrity): The person can say 'I am satisfied with the life I have lived'; they acc… Full explanation →
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A client with depression has not spoken during the last 10 minutes of a scheduled therapeutic interaction. What is the MOST therapeutic nursing response?
- End the session — silence means the client wants to be alone
- Sit quietly with the client, maintaining an open, accepting posture, using therapeutic silence — silence communicates that you are present, attentive, and comfortable without demanding conversation ✓
- Ask a series of questions to fill the silence
- Leave and return when the client is ready to talk
THERAPEUTIC SILENCE is an active, deliberate communication technique — not passive waiting. WHAT THERAPEUTIC SILENCE COMMUNICATES: 'You don't have to perform or produce for me'; 'I am here and attentive without demanding you speak'; 'Whatever you are experiencing right now is okay'; 'You have space … Full explanation →
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A client with major depressive disorder reports: 'I've been feeling much better lately. I've given away my jewelry and written a goodbye letter to my children.' What is the nurse's priority concern?
- This presentation is a HIGH-RISK WARNING for imminent suicide — giving away possessions and writing goodbye letters are behavioral indicators of suicidal intent; the client's reported 'improvement' may reflect resolution of ambivalence after deciding to act; this requires immediate safety assessment and intervention ✓
- The client is recovering and has improved insight
- The client is experiencing a manic episode
- The client needs follow-up in 2 weeks
PARADOXICAL IMPROVEMENT IN DEPRESSION is a well-documented and dangerous phenomenon: EXPLANATION: Severely depressed clients often lack the energy to act on suicidal thoughts; when they 'improve' slightly, they have enough energy to act but their hopelessness has not resolved; their apparent improve… Full explanation →
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A client with bipolar disorder is in a manic episode and has been awake for 3 days. Which nursing intervention is the HIGHEST priority?
- Schedule group therapy
- Ensure safety and promote rest/sleep — the client is in physiological danger from exhaustion, dehydration, and potential for impulsive dangerous behavior; environmental modifications (low stimulation, reduced lighting, quiet) and medication (mood stabilisers, adjunctive sedatives/antipsychotics) are the priority ✓
- Plan recreational activities
- Encourage writing in a journal
MANIA NURSING PRIORITIES: Safety is always first — mania creates serious risks: PHYSICAL: Exhaustion (3 days of sleep deprivation can cause hallucinations and medical complications); dehydration and poor nutrition (too agitated to eat/drink); cardiovascular strain from sustained hyperactivity; BEHAV… Full explanation →
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A bereaved spouse says: 'It's been 14 months since my wife died and I still cry every day — something must be wrong with me.' What is the most appropriate nursing response?
- 'You're right, 14 months is too long — you should seek medication'
- 'Grief has no set timeline. While intense acute grief typically evolves over the first year, it is normal to continue experiencing sadness and missing someone you loved deeply. The question is whether grief is impairing your ability to function in daily life' ✓
- 'By now you should be over it'
- 'You need psychiatric evaluation immediately'
COMPLICATED GRIEF vs NORMAL GRIEF: NORMAL GRIEF: Varies enormously between individuals; no set timeline; acute phase most intense first year; grief does not end — it transforms; sadness and missing the deceased indefinitely is NORMAL; COMPLICATED GRIEF (Prolonged Grief Disorder — DSM-5 2022): Persis… Full explanation →
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A client with terminal cancer says: 'I don't want my family to know how bad the pain is — they worry so much.' What does the nurse do?
- Tell the family everything immediately
- Insist the family must know
- Honour the request completely and tell the family nothing
- Respect the client's decision about disclosure while ensuring their pain is adequately managed — explore the client's concerns about the family's emotional response; offer strategies for pain control that meet the client's needs; remind the client of available support; document the client's preferences ✓
PATIENT CONFIDENTIALITY AND PAIN MANAGEMENT: PATIENT AUTONOMY: The client has the right to control what medical information is shared with family — even at end of life; confidentiality does not end when prognosis is terminal; COMPETING OBLIGATION: The nurse also has an obligation to ensure adequate … Full explanation →
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A teenager with a new type 1 diabetes diagnosis says: 'I don't care about this stupid disease — it won't change anything.' What does the nurse recognise?
- This is normal and requires no response
- This statement may indicate denial or minimisation as a coping mechanism — adolescents with new chronic illness diagnoses often use denial to manage the psychological threat; the nurse should explore the statement without confrontation ✓
- The teenager is ready for discharge
- The teenager is medically compliant and healthy
ADOLESCENT COPING WITH CHRONIC ILLNESS: DEVELOPMENTAL CONTEXT: Adolescents are establishing identity and peer belonging — a diagnosis of a chronic, visible disease (requiring injections, diet management, medical equipment) threatens both; denial and minimisation protect against the full psychologica… Full explanation →
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A client with borderline personality disorder (BPD) tells one nurse: 'You're the only one who understands me — the others are terrible nurses.' What interpersonal dynamic is this and how should the nurse respond?
- The client is being appropriately appreciative
- Splitting — a classic defence mechanism in BPD where people are viewed as all-good or all-bad; the nurse should acknowledge the client's feelings without reinforcing the splitting, maintain consistent boundaries, and communicate the pattern to the care team for consistent approach ✓
- This is the client's right to a favourite nurse
- The other nurses are probably poorly performing
SPLITTING IN BORDERLINE PERSONALITY DISORDER: DEFINITION: Seeing people as entirely good or entirely bad — unable to hold the ambivalent complexity that everyone is both; 'You're wonderful, everyone else is terrible'; RECOGNITION: Is a classic BPD interpersonal pattern; the 'wonderful' nurse gets id… Full explanation →
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A 45-year-old client is admitted for alcohol withdrawal monitoring. Which scale is used to standardise assessment and guide benzodiazepine dosing in alcohol withdrawal?
- Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) — a 10-item scale assessing autonomic symptoms (HR, BP), tremor, diaphoresis, agitation, and hallucinations; scores guide symptom-triggered benzodiazepine administration (e.g., lorazepam if CIWA-Ar > 8-10) ✓
- PHQ-9
- CAGE questionnaire
- Glasgow Coma Scale
CIWA-Ar SCALE: THE STANDARD: Most commonly used validated tool for alcohol withdrawal monitoring; ITEMS: Nausea/vomiting; tremor; diaphoresis; anxiety; agitation; tactile disturbances (formication); auditory disturbances; visual disturbances; headache; orientation/clouding; SCORING: 0-67 total; INTE… Full explanation →
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A nurse is providing therapeutic communication to an anxious pre-operative client. Which statement best demonstrates therapeutic technique?
- 'Thousands of people have this surgery every year without problems'
- 'Tell me what specifically is making you feel anxious about the surgery' ✓
- 'Let me explain the statistics on surgical outcomes'
- 'Don't worry — everything will be fine'
THERAPEUTIC COMMUNICATION — ANXIETY EXPLORATION: BEST RESPONSE: 'Tell me what specifically is making you feel anxious...' REASONS: Open-ended — invites the client to elaborate rather than answer yes/no; Client-specific — focuses on THIS client's concern, not generalisations; Actionable — identifies … Full explanation →
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A client prescribed lithium carbonate asks why they need blood tests. The nurse explains that lithium has a narrow therapeutic range. What are the signs of lithium toxicity?
- Hypertension and tachycardia
- Weight loss and insomnia
- Euphoria and hyperactivity
- Tremors, ataxia, slurred speech, confusion, and vomiting — early toxicity (1.5-2.0 mEq/L); severe toxicity (>2.0 mEq/L): seizures, cardiac arrhythmias, coma; therapeutic range is 0.6-1.2 mEq/L (maintenance) or 0.8-1.2 mEq/L (acute) ✓
LITHIUM TOXICITY — HIGH-YIELD NCLEX CONTENT: THERAPEUTIC RANGE: 0.6-1.2 mEq/L (some sources 0.8-1.2 for bipolar treatment); TOXIC LEVELS: >1.5 mEq/L early toxicity; >2.0 mEq/L serious toxicity; EARLY TOXICITY SIGNS: Coarse tremors; nausea/vomiting; diarrhoea; polyuria; ataxia (coordination problems)… Full explanation →
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A nurse calls security after a client with paranoid schizophrenia becomes increasingly agitated and is threatening to hit staff. After de-escalation fails, the client must be physically restrained. What is the nurse's priority during the restraint process?
- Protect the client's airway and monitor vital signs during and immediately after the restraint — physical restraint carries risk of positional asphyxia (particularly prone restraint), excited delirium, and cardiac events; monitor breathing and oxygenation continuously ✓
- Ensure the most staff are involved to look authoritative
- Focus only on protecting staff
- Document first, then assist
SAFETY DURING PHYSICAL RESTRAINT: RESTRAINT RISKS: POSITIONAL ASPHYXIA: If face-down (prone) restraint is used, chest compression restricts breathing; risk of death; EXCITED DELIRIUM: State of extreme agitation with high sympathetic drive; risk of sudden cardiac death during or after restraint; MONI… Full explanation →
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A nurse notices that a client who was just informed they need chemotherapy immediately begins explaining to family members the detailed biology of cancer cell growth and treatment mechanisms. What coping mechanism is this?
- Regression
- Intellectualisation — using abstract thinking, facts, and intellectual analysis to emotionally distance oneself from the threatening aspects of a diagnosis; the client is engaging with the intellectual content while avoiding emotional processing ✓
- Repression
- Sublimation
INTELLECTUALISATION: Converting a threatening emotional situation into an intellectual exercise to manage anxiety; PRESENTATION: The individual becomes an 'expert' on their diagnosis; researches every detail; discusses statistics and biology; may appear calm and in control; DISTINGUISHED FROM: Healt… Full explanation →
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During a home visit, the nurse observes that a cognitively intact older adult client has bruising in various stages of healing, appears frightened when their adult child is present, and winces when the child reaches toward them. What must the nurse do?
- Assume it is accidental and document the bruises only
- Advise the client to see a doctor
- Ask the adult child what happened and accept their explanation
- This presentation requires mandatory reporting to adult protective services — these are multiple red flags for elder abuse (unexplained bruising in various stages, fear of caregiver, flinching response); nurses are mandatory reporters of suspected elder abuse in all states ✓
ELDER ABUSE IDENTIFICATION AND MANDATORY REPORTING: RED FLAGS PRESENT: Multiple bruises in various stages (suggests repeated injury); fear response to caregiver; flinching (anticipatory fear of being struck); TYPES OF ELDER ABUSE: Physical (most visible); emotional/psychological; sexual; financial; … Full explanation →
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A client is admitted with anorexia nervosa. Which finding is the highest priority for the nurse to monitor?
- The client's distorted body image
- The client's social withdrawal
- Cardiac status and electrolyte imbalances — particularly hypokalemia and cardiac dysrhythmias, which are the leading cause of death in anorexia nervosa ✓
- The client's perfectionism
ANOREXIA NERVOSA — PHYSIOLOGICAL PRIORITY: While the psychological aspects (body image distortion, control issues) are central to the disorder, the IMMEDIATE LIFE THREAT is physiological. CARDIAC AND ELECTROLYTE COMPLICATIONS are the leading cause of death: Hypokalemia (low potassium) → fatal cardia… Full explanation →
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A client with borderline personality disorder tells the nurse, 'You're the only one who understands me. The other nurses are terrible.' What is the best nursing response?
- Agree that the other nurses could do better
- 'Thank you, I do try harder than the others.'
- Avoid the client to prevent the behavior
- Recognize this as 'splitting' (idealization/devaluation) and respond with a consistent, professional approach — set clear boundaries and avoid being drawn into the idealization; the treatment team maintains consistency to avoid manipulation ✓
BORDERLINE PERSONALITY DISORDER — SPLITTING: A hallmark defense mechanism where the client views people as all-good (idealization) or all-bad (devaluation), often shifting rapidly. The statement 'you're the only one who understands me, others are terrible' is classic splitting. NURSING RESPONSE: Mai… Full explanation →
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A client in alcohol withdrawal is being monitored using the CIWA-Ar scale. What does a rising CIWA-Ar score indicate?
- Worsening withdrawal severity — a rising score indicates escalating symptoms and the need for more aggressive treatment (typically benzodiazepine dosing) to prevent progression to seizures or delirium tremens ✓
- Improvement in withdrawal symptoms
- Successful detoxification
- The client is ready for discharge
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised): A validated 10-item scale that quantifies alcohol withdrawal severity. ITEMS: Nausea/vomiting, tremor, sweating, anxiety, agitation, tactile/auditory/visual disturbances, headache, orientation; SCORING: Higher score = more seve… Full explanation →
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A nurse is caring for a client who survived a violent assault. The client is experiencing acute stress and says, 'I keep seeing it happen over and over.' Which intervention is most appropriate during the acute phase?
- Encourage the client to forget about the event
- Provide a safe, calm environment, allow the client to express feelings at their own pace, validate their experience, and ensure basic needs and safety — avoid forcing the client to recount details or pushing for emotional processing prematurely ✓
- Tell the client they are lucky to be alive
- Immediately confront the trauma in detail
ACUTE STRESS / TRAUMA RESPONSE — CRISIS INTERVENTION: In the acute phase after trauma, the priorities are SAFETY, STABILIZATION, and SUPPORT — not deep emotional processing. APPROPRIATE INTERVENTIONS: Ensure physical safety and basic needs; provide a calm, safe environment; allow the client to expre… Full explanation →
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A client is taking lithium for bipolar disorder. The client reports nausea, vomiting, diarrhea, coarse hand tremors, and confusion. What does the nurse suspect?
- Improvement in mood symptoms
- Lithium toxicity — these are signs of elevated lithium levels; hold the lithium, check the serum lithium level, and notify the provider; lithium has a narrow therapeutic range (0.6-1.2 mEq/L) ✓
- Normal side effects that will resolve
- An unrelated viral illness
LITHIUM TOXICITY: Lithium has a NARROW THERAPEUTIC RANGE (0.6-1.2 mEq/L) — toxicity can occur even slightly above range. EARLY TOXICITY (1.5-2.0 mEq/L): Nausea, vomiting, diarrhea, fine tremor worsening, drowsiness, muscle weakness; MODERATE-SEVERE (2.0-2.5+): COARSE tremors, confusion, ataxia, slur… Full explanation →
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A client with major depression states, 'There's no point in any of this. Nothing will ever get better.' What is the priority nursing assessment in response to this statement?
- Assess the client's sleep patterns
- Assess the client's family support
- Assess the client's appetite
- Assess for suicidal ideation — hopelessness and statements suggesting life is pointless are warning signs that require direct assessment of suicidal thoughts, plan, and intent ✓
HOPELESSNESS AND SUICIDE RISK: Statements expressing hopelessness ('nothing will ever get better,' 'no point') are significant suicide warning signs. HOPELESSNESS is one of the strongest predictors of suicide. PRIORITY: Directly assess for suicidal ideation — ask directly: 'Are you having thoughts o… Full explanation →
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A client experiencing a panic attack is hyperventilating and says, 'I think I'm having a heart attack — I'm going to die.' After medical causes are ruled out, what is the most therapeutic nursing intervention?
- Administer oxygen at high flow
- Leave the client alone to calm down
- Tell the client there's nothing wrong and to relax
- Stay with the client, remain calm, speak in short simple sentences, and guide slow breathing — your calm presence and reassurance help the client regain control during the panic attack ✓
PANIC ATTACK — ACUTE NURSING INTERVENTION: Once medical causes (cardiac, respiratory) are ruled out, the therapeutic approach is calm, supportive presence. INTERVENTIONS: STAY with the client (do not leave them alone — abandonment increases panic); remain CALM yourself (anxiety is contagious; calmne… Full explanation →
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A nurse uses the therapeutic communication technique of 'reflection.' Which response is an example of reflection?
- 'You're feeling frightened about the surgery tomorrow.' — reflection restates the client's feelings or content to show understanding and encourage further exploration ✓
- 'Everything will be fine, don't worry.'
- 'You should talk to your doctor about that.'
- 'Why do you feel that way?'
REFLECTION — A THERAPEUTIC COMMUNICATION TECHNIQUE: Reflection restates or mirrors the client's expressed feelings or content, demonstrating active listening and encouraging the client to continue. EXAMPLE: Client: 'I'm so scared about the surgery.' Nurse (reflection): 'You're feeling frightened abo… Full explanation →
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A client with obsessive-compulsive disorder (OCD) performs hand-washing rituals for hours, causing skin breakdown. During the acute phase, what is the most therapeutic initial nursing approach?
- Ignore the behavior completely
- Allow the ritual while ensuring safety (skin care), then gradually work with the treatment team to set limits and reduce the behavior — abruptly preventing a compulsion increases anxiety severely; structure and gradual reduction are therapeutic ✓
- Prevent the client from performing the ritual entirely
- Punish the client when they perform the ritual
OCD — COMPULSIONS AND NURSING APPROACH: Compulsions are anxiety-reducing rituals; the client feels compelled to perform them to relieve obsession-driven anxiety. INITIAL APPROACH: Do NOT abruptly stop the ritual — preventing a compulsion suddenly causes severe, sometimes intolerable anxiety; ALLOW t… Full explanation →
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A nurse is assessing a client who may be a victim of intimate partner violence (IPV). What is the most appropriate way to conduct this assessment?
- Interview the client ALONE, in a private and safe setting, using direct but nonjudgmental questions — never assess for abuse in the presence of the suspected abuser ✓
- Wait for the client to bring it up themselves
- Only assess if there are visible injuries
- Ask about abuse in front of the client's partner
INTIMATE PARTNER VIOLENCE (IPV) ASSESSMENT: PRIVACY AND SAFETY: Always interview the client ALONE — never assess for abuse with the partner present (the abuser may control the narrative, intimidate, or the client may fear retaliation); ensure a private, safe setting; APPROACH: Direct but nonjudgment… Full explanation →
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A nurse is caring for a client with dementia who becomes agitated and combative in the late afternoon and evening. This pattern is known as:
- Sundowning — increased confusion, agitation, and behavioral disturbances that occur in the late afternoon and evening in clients with dementia; managed with environmental and routine modifications ✓
- Delirium
- Catatonia
- Psychosis
SUNDOWNING: A pattern of increased confusion, agitation, anxiety, and behavioral disturbances that occurs in the LATE AFTERNOON AND EVENING in some clients with dementia. CONTRIBUTING FACTORS: Fatigue, reduced lighting/increased shadows, disrupted circadian rhythm, overstimulation or understimulatio… Full explanation →
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A client who is grieving the recent death of a spouse says, 'I just don't know how I'll go on without them.' What is the most therapeutic response?
- 'You're feeling lost and overwhelmed right now. Tell me about your spouse.' — acknowledging the feeling and inviting the client to share supports healthy grieving ✓
- 'Time heals all wounds. You'll feel better soon.'
- 'At least they're not suffering anymore.'
- 'You need to stay strong for your family.'
GRIEF SUPPORT — THERAPEUTIC COMMUNICATION: The most therapeutic response acknowledges the client's feelings and invites them to express their grief. EXAMPLE: Reflecting the feeling ('you're feeling lost and overwhelmed') and inviting expression ('tell me about your spouse') validates the grief and s… Full explanation →
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A client is prescribed an MAOI (monoamine oxidase inhibitor) antidepressant. Which dietary teaching is essential?
- Avoid foods high in tyramine (aged cheeses, cured meats, fermented foods, draft beer, soy sauce) — combining MAOIs with tyramine can cause a hypertensive crisis, a life-threatening emergency ✓
- Drink grapefruit juice daily
- Avoid all carbohydrates
- Increase protein intake
MAOI DIETARY RESTRICTIONS — TYRAMINE: MAOIs (phenelzine, tranylcypromine, isocarboxazid, selegiline) inhibit the enzyme that breaks down tyramine; consuming tyramine-rich foods while on an MAOI causes a dangerous spike in blood pressure (HYPERTENSIVE CRISIS). TYRAMINE-RICH FOODS TO AVOID: Aged chees… Full explanation →
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During a community disaster with mass casualties, the mental health nurse is providing psychological first aid. What is the primary goal of psychological first aid?
- Identify who needs psychiatric hospitalization
- Provide formal psychotherapy on-site
- Reduce initial distress, meet immediate needs, and foster adaptive coping and a sense of safety — psychological first aid is supportive, practical, and aims to stabilize, not to provide formal therapy or force people to process the trauma ✓
- Diagnose mental health disorders
PSYCHOLOGICAL FIRST AID (PFA): An evidence-informed approach for helping people in the immediate aftermath of disaster or trauma. PRIMARY GOALS: Reduce initial distress; meet immediate practical needs (safety, food, shelter, information); foster adaptive coping and resilience; connect people with su… Full explanation →
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A client is being treated with electroconvulsive therapy (ECT) for severe, treatment-resistant depression. What is the most common side effect the nurse should anticipate and address?
- Permanent personality change
- Paralysis
- Hair loss
- Transient memory loss and confusion — short-term memory impairment and temporary confusion are the most common side effects after ECT; they typically resolve over days to weeks ✓
ELECTROCONVULSIVE THERAPY (ECT): An effective treatment for severe, treatment-resistant depression, acute mania, and catatonia, especially when rapid response is needed or medications have failed. PROCEDURE: Brief electrical stimulation induces a controlled seizure under general anesthesia with a mu… Full explanation →
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A client with depression states, 'I just don't see the point in anything anymore.' What is the nurse's priority response?
- 'Things will get better soon.'
- Change the subject to something positive
- 'You have so much to live for.'
- Assess for suicidal ideation by asking directly, 'Are you having thoughts of harming yourself or ending your life?' ✓
A statement of HOPELESSNESS ('don't see the point in anything') from a depressed client is a potential warning sign — the PRIORITY is to ASSESS for SUICIDAL IDEATION by asking DIRECTLY ('Are you having thoughts of harming yourself or ending your life?'). NCLEX psychosocial/mental health safety. Aski… Full explanation →
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A client is crying after receiving difficult news. Which nursing action best demonstrates therapeutic presence?
- Leave the room to give privacy and avoid intruding
- Immediately offer detailed medical advice
- Tell the client to stop crying
- Sit with the client, offer a tissue, and allow silence, conveying support and a willingness to listen ✓
Therapeutic PRESENCE after difficult news: SIT WITH the client, offer comfort (a tissue), and ALLOW SILENCE — conveying support, empathy, and a willingness to listen without rushing. NCLEX psychosocial/therapeutic communication. SILENCE is a therapeutic technique — it gives the client time to proces… Full explanation →
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A nurse is caring for a client experiencing a manic episode (bipolar disorder). Which intervention is appropriate?
- Encourage participation in highly stimulating group activities
- Engage the client in lengthy detailed conversations
- Serve large sit-down meals
- Provide a calm, low-stimulation environment and offer high-calorie finger foods the client can eat while moving ✓
For a client in a MANIC episode (hyperactivity, racing thoughts, poor judgment, distractibility, decreased need for sleep, risk-taking): provide a CALM, LOW-STIMULATION environment (reduces escalation); offer HIGH-CALORIE, easy-to-eat FINGER FOODS the client can consume WHILE MOVING (manic clients o… Full explanation →
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A nurse suspects that a client may be a victim of domestic abuse. What is the most appropriate nursing action?
- Interview the client ALONE (without the suspected abuser present), in a private, nonjudgmental manner, and assess for safety ✓
- Tell the client to leave the relationship immediately
- Confront the suspected abuser directly
- Ignore it unless the client brings it up
When abuse is suspected, the nurse should interview the client ALONE — separating them from the suspected abuser (who may control or speak for the victim) — in a PRIVATE, safe, NONJUDGMENTAL setting, and assess for safety. NCLEX psychosocial/abuse. KEY ACTIONS: ensure privacy and the abuser is not p… Full explanation →
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A client with anorexia nervosa is hospitalized. During meals, which nursing approach is most therapeutic?
- Provide a supportive, structured mealtime environment and observe the client during and after meals (to prevent purging or food disposal) ✓
- Allow the client to eat alone without observation
- Force-feed the client immediately
- Comment on every bite the client takes
For a hospitalized client with ANOREXIA NERVOSA, mealtime care includes: a SUPPORTIVE, STRUCTURED environment with consistent expectations; OBSERVING the client DURING and AFTER meals (typically remaining with them and for a period after — often ~1 hour — to prevent hiding/disposing of food, purging… Full explanation →