Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?
A. "ECT is an effective treatment for personality disorders."
A- "ECT is an effective treatment for personality disorders." While ECT may be used in certain cases of severe mental illness, it is not primarily indicated for personality disorders.
B. "It is a myth that clients experience seizures during ECT."
B- "It is a myth that clients experience seizures during ECT." Seizures are a common and expected effect of ECT. ECT involves the induction of controlled seizures under anesthesia.
C. "Informed consent should be obtained prior to ECT."
Obtaining informed consent is a crucial step before administering electroconvulsive therapy (ECT). Informed consent ensures that the client is fully informed about the procedure, its potential risks and benefits, and any alternative treatments available. It allows the client to make an autonomous decision regarding their treatment.
D. "should monitor the client closely for hypotension following ECT."
D- "Should monitor the client closely for hypotension following ECT." While monitoring the client for various physiological changes is important, hypotension is not a primary concern following ECT. The nurse would typically monitor for potential adverse effects such as confusion, memory loss, headache, and muscle soreness.
This question is an excerpt from Nurse Dive's nursing test bank - Fall 2022 N 517 Mental Health Proctored Exam 2. Take the full exam now
Full Explanation
Obtaining informed consent is a crucial step before administering electroconvulsive therapy (ECT). Informed consent ensures that the client is fully informed about the procedure, its potential risks and benefits, and any alternative treatments available. It allows the client to make an autonomous decision regarding their treatment.
The other responses are not accurate:
A- "ECT is an effective treatment for personality disorders." While ECT may be used in certain cases of severe mental illness, it is not primarily indicated for personality disorders.
B- "It is a myth that clients experience seizures during ECT." Seizures are a common and expected effect of ECT. ECT involves the induction of controlled seizures under anesthesia.
D- "Should monitor the client closely for hypotension following ECT." While monitoring the client for various physiological changes is important, hypotension is not a primary concern following ECT. The nurse would typically monitor for potential adverse effects such as confusion, memory loss, headache, and muscle soreness.
Similar Questions
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
A. Recognizing the warning signs of suicide
A- Recognizing the warning signs of suicide: This is an example of primary intervention, which focuses on preventing suicidal behavior before it occurs by raising awareness, promoting mental health, and identifying risk factors and warning signs.
B. Identifying individuals who are at higher risk for attempting suicide
B- Identifying individuals who are at higher risk for attempting suicide: This is also an example of primary intervention, as it involves assessing and identifying individuals who may be at greater risk for suicidal behavior and implementing preventive measures.
C. Performing life-saving measures following a suicide attempt
Secondary interventions are aimed at reducing the harm or preventing further complications in individuals who have already engaged in suicidal behavior. In this case, performing life-saving measures after a suicide attempt, such as cardiopulmonary resuscitation (CPR) or administering first aid, falls under the category of secondary intervention.
D. Providing support for family and friends following a suicide
D- Providing support for family and friends following a suicide: This is an example of tertiary intervention, which aims to provide support and care to those who have been affected by a suicide, including family and friends. Tertiary interventions focus on postvention, addressing the aftermath and providing support for survivors.
Full Explanation
Secondary interventions are aimed at reducing the harm or preventing further complications in individuals who have already engaged in suicidal behavior. In this case, performing life-saving measures after a suicide attempt, such as cardiopulmonary resuscitation (CPR) or administering first aid, falls under the category of secondary intervention.
The other options are examples of primary and tertiary interventions:
A- Recognizing the warning signs of suicide: This is an example of primary intervention, which focuses on preventing suicidal behavior before it occurs by raising awareness, promoting mental health, and identifying risk factors and warning signs.
B- Identifying individuals who are at higher risk for attempting suicide: This is also an example of primary intervention, as it involves assessing and identifying individuals who may be at greater risk for suicidal behavior and implementing preventive measures.
D- Providing support for family and friends following a suicide: This is an example of tertiary intervention, which aims to provide support and care to those who have been affected by a suicide, including family and friends. Tertiary interventions focus on postvention, addressing the aftermath and providing support for survivors.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
A. Give the client a PRN sleeping medication.
A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.
B. Explore alternatives to pacing the floor with the client.
B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.
C. Encourage the client to go back to bed.
C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.
D. Remain with the client.
Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.
Full Explanation
Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.
A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.
B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.
C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.
A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?
A. "Most clients with anxiety issues benefit from lying down."
A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.
B. "An antianxiety pill works best for situations like this."
B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.
C. "Providers usually recommend relaxation exercises for clients who are as upset as you are."
C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.
D. "Come with me to an area where we can talk without interruption."
This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.
Full Explanation
This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.
A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.
B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.
C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.