Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months.
She notes that her mother does not respond when the mother’s back is turned. What is the best intervention for the nurse?
A. Teach the client techniques for coping with the mother’s anger.
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
B. Ask if the mother could come in for a hearing evaluation.
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
C. Tell the client it appears the mother has a hearing loss.
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
D. Inform the client to ignore the behavior and treat the mother with love.
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.
This question is an excerpt from Nurse Dive's nursing test bank - Lpn Ati Mental Health Psychosocial Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
Choice B rationale
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
Choice C rationale
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
Choice D rationale
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.
Similar Questions
Upon entrance into a mental health care system, clients are thoroughly assessed, and this is followed by the development of a mental health treatment plan assessment.
Which of the following are purposes of the treatment plan? (Select all that apply)
A. An instrument for communication and coordination of care.
A treatment plan serves as an instrument for communication and coordination of care among the healthcare team. It ensures that all members of the team are on the same page regarding the client’s care.
B. Evaluating the effectiveness of interventions.
The treatment plan helps in evaluating the effectiveness of interventions. By comparing the client’s progress to the goals set in the treatment plan, the healthcare team can determine whether the interventions are working or if they need to be adjusted.
C. A guide for planning and implementation of care.
The treatment plan guides the planning and implementation of care. It outlines the steps that need to be taken to help the client achieve their health goals.
D. Ensure that the client follows their treatment.
Ensuring that the client follows their treatment is not a purpose of the treatment plan. While the treatment plan can guide the client’s treatment, it is ultimately up to the client to adhere to the treatment.
E. A means of monitoring the client’s progress.
The treatment plan serves as a means of monitoring the client’s progress. Regular reviews of the treatment plan can show whether the client is making progress towards their health goals.
Full Explanation
Choice A rationale
A treatment plan serves as an instrument for communication and coordination of care among the healthcare team. It ensures that all members of the team are on the same page regarding the client’s care.
Choice B rationale
The treatment plan helps in evaluating the effectiveness of interventions. By comparing the client’s progress to the goals set in the treatment plan, the healthcare team can determine whether the interventions are working or if they need to be adjusted.
Choice C rationale
The treatment plan guides the planning and implementation of care. It outlines the steps that need to be taken to help the client achieve their health goals.
Choice D rationale
Ensuring that the client follows their treatment is not a purpose of the treatment plan. While the treatment plan can guide the client’s treatment, it is ultimately up to the client to adhere to the treatment.
Choice E rationale
The treatment plan serves as a means of monitoring the client’s progress. Regular reviews of the treatment plan can show whether the client is making progress towards their health goals.
Prozac 30mg PO is ordered for a client.
Prozac is available in 10mg tablets.
How many tablets will you administer?
Full Explanation
Step 1 is to determine the number of tablets to administer. The order is for 30mg and each tablet contains 10mg. So, 30mg ÷ 10mg/tablet = 3 tablets.
Therefore, you will administer 3 tablets.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.
Which of the following nursing diagnoses has the highest priority?
A. Ineffective coping related to inadequate stress management.
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
B. Hopelessness related to recent divorce.
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
C. Spiritual distress related to conflicting thoughts about suicide and sin.
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
D. Risk for suicide related to highly lethal plan.
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.
Full Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this situation. The client’s life is not immediately at risk due to ineffective coping.
Choice B rationale
Hopelessness related to recent divorce is a significant concern, but it is not the highest priority. The immediate threat to the client’s life is the suicidal ideation with a highly lethal plan.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin is a potential nursing diagnosis for this client. However, the immediate life-threatening issue takes precedence.
Choice D rationale
Risk for suicide related to highly lethal plan is the highest priority nursing diagnosis. The client has a plan to commit suicide with a handgun, which is a highly lethal method. Immediate intervention is required to ensure the client’s safety.