Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client diagnosed with severe Alzheimer's has been admitted to a long term care facility. Which of the following are appropriate activities for the nurse to include in the care plan?
A. Simple puzzles
Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
B. Board games
Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
C. Dangling ribbons or a mobile
Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
D. Drawing with crayons
Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Paediatrics Proctored Exam 1. Take the full exam now
Full Explanation
Choice A Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
Choice B Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
Choice C Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
Choice D Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
Similar Questions
When asked to explain the common symptoms of Bell's Palsy, the nurse correctly identifies which of the following as manifestations of this disorder?
A. Ringing in the ears that occurs more frequently in the early morning
Rationale: Ringing in the ears (tinnitus) is not a common symptom of Bell's Palsy. Bell's Palsy primarily affects facial muscles.
B. Bilateral pain from the neck upward
Rationale: Bilateral pain from the neck upward is not a typical manifestation of Bell's Palsy. Bell's Palsy typically affects one side of the face.
C. Progressive loss of ability to use all facial muscles
Rationale: Progressive loss of ability to use all facial muscles is not the usual pattern of Bell's Palsy. It typically presents with sudden unilateral weakness of the face.
D. Sudden unilateral weakness of the face
Rationale: Sudden unilateral weakness of the face is a hallmark symptom of Bell's Palsy. This condition often causes weakness or paralysis of the facial muscles on one side of the face, leading to facial drooping.
Full Explanation
Choice A Rationale: Ringing in the ears (tinnitus) is not a common symptom of Bell's Palsy. Bell's Palsy primarily affects facial muscles.
Choice B Rationale: Bilateral pain from the neck upward is not a typical manifestation of Bell's Palsy. Bell's Palsy typically affects one side of the face.
Choice C Rationale: Progressive loss of ability to use all facial muscles is not the usual pattern of Bell's Palsy. It typically presents with sudden unilateral weakness of the face.
Choice D Rationale: Sudden unilateral weakness of the face is a hallmark symptom of Bell's Palsy. This condition often causes weakness or paralysis of the facial muscles on one side of the face, leading to facial drooping.
When educating a client about tetanus, which of the following will the nurse include in teaching? Select All that Apply
A. Affects only the spinal cord
Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.
B. Manifestations include sustained muscle contractions
Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.
C. Follows a recent viral infection
Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.
D. Bacteria is found in improperly processed foods
Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.
E. Spores are found in soil, gardens, and manure
Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.
Full Explanation
Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.
Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.
Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.
Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.
Choice E Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?
A. Assess the client for bladder distention.
Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
B. Lay the client flat
Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
C. Obtain the client's heart rate.
Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
D. Administer a nitrate antihypertensive.
Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
Full Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.