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Question 1 of 5

A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be

Correct Answer: D

Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.

Question 2 of 5

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.

Correct Answer: B,C

Rationale: Breaking the ampule away from the body (
B) and disposing in a sharps container (
C) are safe practices. An 18-gauge needle (
A) is too large, injecting air (
D) is unnecessary, and resting the needle on the rim (E) risks contamination.

Question 3 of 5

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

Correct Answer: A,B,D

Rationale: Bed alarms (
A), hourly rounding (
B), and proximity to the nurses' station (
D) enhance safety and monitoring. Catheters (
C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.

Question 4 of 5

The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?

Correct Answer: D

Rationale: A slice of cheese (
D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (
A) is high in sugar, sweetened cereal (
B) lacks nutritional value, and raw carrot sticks (
C) pose a choking hazard.

Question 5 of 5

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply.

Correct Answer: A,C,E

Rationale: Palliative care aims to improve quality of life and can be provided at any stage of illness (
A). It involves a multidisciplinary team to address various needs (
C). It also focuses on symptom relief for chronic illnesses (E). Palliative care is not limited to terminal diagnoses (B is incorrect) and is distinct from hospice care, which is specifically for end-of-life (D is incorrect).

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A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?

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