Question

A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client?

Answer 1

Correct Answers:

Wheat toast with peanut butter

Rationale :

🌱A vegan diet excludes all animal-derived foods, including meat, eggs, milk, cheese, and yogurt.

🥜Wheat toast with peanut butter is appropriate because it contains plant-based grains and plant-based protein.

🍞The wheat toast provides carbohydrates and fiber, while peanut butter adds protein and healthy fats.

🫘This option supports the client’s dietary preference while still offering nutritional value and energy.

📌Core Message

A client who follows a vegan diet should be offered foods that contain no animal products, making wheat toast with peanut butter the best choice.

Answer 2

Correct Answers:

Paraphrasing

Rationale :

🗣️Paraphrasing is the most appropriate technique when the nurse needs to check whether the client’s message has been understood correctly.

🧠This technique involves restating the client’s words or meaning in a clear and simple way.

💬It gives the client an opportunity to confirm, clarify, or correct the nurse’s interpretation.

🤝Using paraphrasing strengthens therapeutic communication because it shows active listening and respect for the client’s perspective.

📌Core Message

Paraphrasing helps the nurse verify accurate interpretation of the client’s words while supporting effective therapeutic communication.

Answer 3

Correct Answers:

Tell the client to seek out staff when feeling agitated

Rationale :

⚠️A client experiencing mania can become impulsive, overstimulated, and easily agitated.

🛡️Encouraging the client to seek staff support early helps prevent escalation into unsafe behavior.

💁‍♂️This action promotes early intervention before agitation becomes harmful to the client or others.

🌪️Because flight of ideas and grandiosity can impair judgment, staff guidance helps provide structure and safety.

📌Core Message

Clients with mania should be encouraged to seek staff support early to prevent escalation and maintain safety.

Answer 4

Correct Answers:

"You should keep your provider's and therapist's telephone numbers with you."

Rationale :

📞A relapse plan should include immediate access to provider and therapist contact information.

🧠Clients with psychosis may experience early warning signs that require timely professional support.

💁‍♂️Keeping emergency or treatment contacts available helps promote rapid intervention.

🤝This plan supports continuity of care and helps reduce the risk of worsening symptoms.

📌Core Message

A psychosis relapse plan should include accessible provider contacts so early symptoms can be addressed quickly and safely.

Answer 5

Correct Answers:

Self-esteem

Rationale :

👑A belief that one has a special mission from God is a type of grandiose delusion.

🧠Grandiose delusions often protect or enhance the client’s self-esteem.

🌟This belief may help the client feel powerful, important, or specially chosen during impaired reality testing.

🧩Recognizing this purpose helps the nurse respond with therapeutic communication rather than arguing with the delusion.

📌Core Message

A grandiose delusion often serves to protect or enhance self-esteem when reality testing is impaired.

Answer 6

Correct Answers:

"You are frightened. Come with me to your room and we can talk about it."

Rationale :

😟This response validates the client’s fear without agreeing with the delusional belief.

🧠Clients with persecutory delusions need emotional support and safe redirection.

🗣️The nurse focuses on the client’s feelings rather than arguing about whether the belief is true.

🛡️Moving the client to a quieter area supports safety and helps decrease anxiety.

📌Core Message

For persecutory delusions, the nurse should validate fear, promote safety, and avoid reinforcing the delusion.

Answer 7

Correct Answers:

Spending time sitting with the client

Rationale :

🪑A client with catatonic features may have reduced movement, speech, and interaction.

🤝Sitting quietly with the client provides therapeutic presence without placing demands on the client.

🧠This intervention respects the client’s limited ability for active participation.

🌿Calm presence helps reduce isolation and supports psychological safety during severe depression.

📌Core Message

Severe depression with catatonic features requires calm therapeutic presence and low-demand emotional support.

Answer 8

Correct Answers:

A 3-month-old infant who is lethargic after allegedly rolling off a changing table

Rationale :

🚨A lethargic infant after a reported fall is highly concerning because lethargy may indicate serious neurologic injury.

👶A 3-month-old has limited mobility, so the injury story must match the infant’s developmental ability.

🧠Young infants are especially vulnerable to head trauma and rapid clinical deterioration.

🏥The combination of altered responsiveness and questionable injury mechanism raises concern for nonaccidental trauma.

📌Core Message

Lethargy in a young infant after a questionable injury history is a major warning sign for possible child abuse.

Answer 9

Correct Answers:

Anhedonia

Rationale :

😶Anhedonia is a negative symptom because it reflects reduced ability to experience pleasure.

🧠Negative symptoms involve a decrease in normal emotion, motivation, speech, or social engagement.

🌫️Clients with schizophrenia may show reduced interest in activities because of impaired emotional expression.

📉Identifying anhedonia is important because it affects functioning, relationships, and treatment participation.

📌Core Message

Anhedonia is a negative symptom of schizophrenia because it reflects reduced pleasure and emotional engagement.

Answer 10

Correct Answers:

Acceptance

Rationale :

🕊️Acceptance is often shown by calmness, emotional quietness, and readiness.

🌿A client who appears detached and peaceful may be acknowledging the reality of a terminal illness.

🧠This stage does not mean happiness, but it reflects reduced emotional struggle with impending death.

🤝The nurse should provide supportive presence and respect the client’s emotional state.

📌Core Message

Acceptance may appear as calm detachment when a client has emotionally acknowledged a terminal illness.

1 :
A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client?

2 :
A nurse is assigned to a newly admitted client on a psychiatric unit. When discussing the client's condition and treatment plan, which of the following techniques is most appropriate for the nurse to assess the accuracy of interpretation of the client's words?

3 :
A nurse is caring for a client with bipolar disorder and mania who has flight of ideas and grandiosity and becomes easily agitated. Which of the following is an appropriate initial action by the nurse to prevent harmful behaviors?

4 :
A nurse is conducting discharge teaching about a relapse plan with a client who has psychosis. Which of the following statements should the nurse make?

5 :
A nurse is caring for a client who claims to have a special mission from God. Which of the following is the primary purpose of this delusion?

7 :
A nurse is planning care for a client who has severe depression with catatonic features. Which of the following interventions should the nurse include in the client's plan?

8 :
Which pediatric presentation is most concerning for child abuse when evaluating clients in the emergency department?

9 :
A nurse is caring for a client with schizophrenia. Which of the following is a negative symptom of psychosis anticipated by the nurse?

10 :
A nurse is caring for a client with a terminal illness who seems detached and calm. Which of the following stages of dying is consistent with this presentation?

1 : A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client?

2 : A nurse is assigned to a newly admitted client on a psychiatric unit. When discussing the client's condition and treatment plan, which of the following techniques is most appropriate for the nurse to assess the accuracy of interpretation of the client's words?

3 : A nurse is caring for a client with bipolar disorder and mania who has flight of ideas and grandiosity and becomes easily agitated. Which of the following is an appropriate initial action by the nurse to prevent harmful behaviors?

4 : A nurse is conducting discharge teaching about a relapse plan with a client who has psychosis. Which of the following statements should the nurse make?

5 : A nurse is caring for a client who claims to have a special mission from God. Which of the following is the primary purpose of this delusion?

7 : A nurse is planning care for a client who has severe depression with catatonic features. Which of the following interventions should the nurse include in the client's plan?

8 : Which pediatric presentation is most concerning for child abuse when evaluating clients in the emergency department?

9 : A nurse is caring for a client with schizophrenia. Which of the following is a negative symptom of psychosis anticipated by the nurse?

10 : A nurse is caring for a client with a terminal illness who seems detached and calm. Which of the following stages of dying is consistent with this presentation?

1 :
A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client?

2 :
A nurse is assigned to a newly admitted client on a psychiatric unit. When discussing the client's condition and treatment plan, which of the following techniques is most appropriate for the nurse to assess the accuracy of interpretation of the client's words?

3 :
A nurse is caring for a client with bipolar disorder and mania who has flight of ideas and grandiosity and becomes easily agitated. Which of the following is an appropriate initial action by the nurse to prevent harmful behaviors?

4 :
A nurse is conducting discharge teaching about a relapse plan with a client who has psychosis. Which of the following statements should the nurse make?

5 :
A nurse is caring for a client who claims to have a special mission from God. Which of the following is the primary purpose of this delusion?

7 :
A nurse is planning care for a client who has severe depression with catatonic features. Which of the following interventions should the nurse include in the client's plan?

8 :
Which pediatric presentation is most concerning for child abuse when evaluating clients in the emergency department?

9 :
A nurse is caring for a client with schizophrenia. Which of the following is a negative symptom of psychosis anticipated by the nurse?

10 :
A nurse is caring for a client with a terminal illness who seems detached and calm. Which of the following stages of dying is consistent with this presentation?