2026\2027 A+ Grade
A nurse is caring for a client who lost all his possessions in a house fire and states, "i have no idea what i
am going to do. I cannot even think right now". Which of the following actions should the nurse take?
A-Identify other housing options and sources of transportation
B- notify the facility chaplain to request scheduling an appointment
c- confirm that everything will be alright because belongings can be replaced
d-maintain eye contact with client and summarize the client's feelings
- correct answer d- this demonstrates therapeutic communication. during the initial interview, it is
important for the nurse to provide an atmosphere of support and safety. If a person believes that
someone is genuinely concerned, then he may believe that help is available. Maintaining eye contact
demonstrates support, empathy, and advocacy.
- do not offer false hope, instead focus on the feelings of the client and his unique response to the crisis
-you should help the client identify sources of support ( do not do it for them or presume what is best
- it can be overwhelming to the client to think about housing and transportation and they are immediate
needs but right now the nurse should focus on the feelings of the client
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should
the nurse expect?
a- Hypotension
b- viral infection
c- increased energy
,d- increased cognitive awareness
- correct answer B-viral infection because chronic stress can cause a decreased immune response which
leads to viral or bacterial infections
-the nurse should expect to find the client hypertensive due to increased cardiac tone from the response
to chronic stress
- you would expect to find decreased energy and decreased memory and ability to learn
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed
after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic
in helping the child deal with the injection?
a- a needless syringe and a doll
b- a video game
c- a story book about a child who has diabetes
d- a period of play in the playroom
- correct answer a- this a therapeutic activity for a child because they will allow the child to act out
feelings of anger and helplessness
-a video game is a distraction, the activity book does not provide an outlet for working out the feelings
that a child is unable to verbalize, playing in the playroom is not therapeutic in this activity
A nurse is admitting a client who has experienced a weight-loss of 11 kg/25 Lbs in 3 months. The client
weighs 40 kg(88lbs) and believes she is fat. Which of the following aspects of care should the nurse
consider the first priority of care for this client?
a- identify the client's nutritional status
b- request a mental health consult
c-plan a therapeutic diet for the client
d- provide a structured environment for the client
- correct answer A- according to the nursing process the nurse should perform an assessment first to
gather data regarding nutritional status and other findings in order to plan, implement, and evaluate
care.
, - mental health consult might be necessary but another aspect of care is priority
-it is important to provide structured environments for the client regarding meal times, for weighing,
and monitoring eating- but other aspects of care is the priority
A nurse at a college campus mental health counseling center is caring for a student who just failed an
exam. The student spends the session berating the teacher and the course. The nurse should recognize
this behavior as which of the following defense mechanisms?
a- conversion
b- projection
c- undoing
d- regression
- correct answer B- the client is refusing to acknowledge unacceptable personal characteristics and
transfers feelings, thought and traits onto another person.
-conversion as a defense mechanism in which the client unconsciously expresses emotional conflict via
physical symptoms - such as paralysis or loss of sensory function
-undoing is a defense mechanism in which the client takes an action to make up for a wrong action or
statement
-regression is a defense mechanism in which the client adopts a more primitive, immature behavior in
response to an unwanted situation
a nurse is caring for a client who was involved in a heavy combat and observed war casualties. The nurse
should suspect that the client is suffering PTSD if the client makes which of the following statements?
a-"I check any room I enter because the enemy is still after me and could be hiding anywhere"
b-" My child was born with a birth defect due to an exposure I had overseas"
c-"I killed four enemy soldiers with my bare hands and saved my entire battalion."
d- "In my dreams, all I can see are the wounded reaching out and trying to grab me."
- correct answer d- Many clients with PTSD repeatedly re-experience the ordeal in the form of flashback
episodes, memories, nightmares, or frightening thoughts, especially when exposed to events or objects
reminiscent of the trauma.