Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client is agitated and pacing in the hall near the nurses' station and swearing loudly. What response is the best for the registered nurse to provide?
Select one:
A. Others are being distracted; Please, quiet down and go to your room.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
B. You seem pretty upset. Tell me about it
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
C. Please go to your room to get control of yourself.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
D. What’s going on? Be quiet.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health - Proctored Exam 2. Take the full exam now
Full Explanation
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Similar Questions
Lorazepam (Ativan) is prescribed for a client experiencing severe acute anxiety. Most important teaching should include instructions to:
A. avoid taking opioid medications and other sedatives.
Lorazepam belongs to a class of drugs called benzodiazepines, which are central nervous system (CNS) depressants. Taking other CNS depressants such as opioids or sedatives along with lorazepam can lead to increased sedation, respiratory depression, and other serious side effects. It is crucial for patients to avoid these medications while taking lorazepam.
B. report insomnia
Reporting insomnia is important, but it is not the most critical teaching for this medication. Eating a tyramine-free diet is not relevant to lorazepam use.
C. eat a tyramine-free diet.
D. adjust dose and frequency based on your anxiety level.
Adjusting the dose and frequency based on anxiety level is not recommended as it can lead to misuse or dependence on the medication. It is important to take lorazepam only as prescribed by a healthcare provider.
Full Explanation
Lorazepam belongs to a class of drugs called benzodiazepines, which are central nervous system (CNS) depressants.
Taking other CNS depressants such as opioids or sedatives along with lorazepam can lead to increased sedation, respiratory depression, and other serious side effects. It is crucial for patients to avoid these medications while taking lorazepam.
Reporting insomnia is important, but it is not the most critical teaching for this medication. Eating a tyramine-free diet is not relevant to lorazepam use.
Adjusting the dose and frequency based on anxiety level is not recommended as it can lead to misuse or dependence on the medication. It is important to take lorazepam only as prescribed by a healthcare provider.
When reviewing the admission assessment, the Registered nurse notes that a client was admitted to the mental health unit with involuntarily status. Based on this type of admission, the registered nurse should provide which intervention for this client?
Select one:
A. Monitor closely for opioid overdose.
Option a is more appropriate for a client with a history of opioid use.
B. Monitor closely for harm to a family member.
Option b is more appropriate for a client with a history of violence or aggression towards family members.
C. Monitor closely for severe anxiety and stress.
When a client is admitted with an involuntary status, it means that the client did not consent to the admission and was likely admitted due to being a danger to themselves or others. This can lead to increased stress and anxiety for the client, so the nurse should closely monitor the client for signs of severe anxiety and stress. Options a, b, and d are not appropriate interventions for a client admitted with an involuntary status.
D. Monitor closely for using Methamphetamines.
Option d is more appropriate for a client with a history of methamphetamine use.
Full Explanation
When a client is admitted with an involuntary status, it means that the client did not consent to the admission and was likely admitted due to being a danger to themselves or others. This can lead to increased stress and anxiety for the client, so the nurse should closely monitor the client for signs of severe anxiety and stress.
Options a, b, and d are not appropriate interventions for a client admitted with an involuntary status.
Option a is more appropriate for a client with a history of opioid use.
Option b is more appropriate for a client with a history of violence or aggression towards family members.
Option d is more appropriate for a client with a history of methamphetamine use.
A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
A. Identify the clients’ coping skills.
B. Determine the cause of the client's anxiety.
C. Ensuring that the client feels safe.
D. Protecting the client from injury
Full Explanation
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.