Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.
A. "Having a newborn must be stressful. Do you have other children?".
A rationale: While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
B. "Tell me about your baby. Where is she now?".
B rationale: This response is the priority as it assesses the immediate safety of the baby.
C. "Do you have a friend who could help you?".
C rationale: While support is important, the immediate safety of the baby is the priority.
D. "Have you discussed this with your partner?".
D rationale: While communication with the partner is important, the immediate safety of the baby is the priority.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
Choice B rationale:
This response is the priority as it assesses the immediate safety of the baby.
Choice C rationale:
While support is important, the immediate safety of the baby is the priority.
Choice D rationale:
While communication with the partner is important, the immediate safety of the baby is the priority.
Similar Questions
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.
The caregiver reports that the client awakens at night and wanders.
Which of the following strategies should the nurse suggest?.
A. Use light restraints while the client is in bed.
A rationale: Using restraints can lead to injury and is generally a last resort.
B. Place a lock at the top of doors leading outside.
B rationale: Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
C. Encourage the client to nap during the day.
C rationale: Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
D. Administer an antianxiety medication before bedtime.
D rationale: While medication can be helpful, non-pharmacological interventions should be tried first.
Full Explanation
Choice A rationale:
Using restraints can lead to injury and is generally a last resort.
Choice B rationale:
Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
Choice C rationale:
Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
Choice D rationale:
While medication can be helpful, non-pharmacological interventions should be tried first.
A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.
A. Reinforce teaching on the client's use of coping skills
A rationale: Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
B. Encourage the client to use personal support systems.
B rationale: Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
C. Assist with a client referral for social services.
C rationale: Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
D. Identify if the client has thoughts of self-harm.
D rationale: Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.
Full Explanation
Choice A rationale:
Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
Choice B rationale:
Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
Choice C rationale:
Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
Choice D rationale:
Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.
A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder.
Which of the following strategies should the nurse plan to use?.
A. Demonstrate a neutral demeanor.
A rationale: Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.
B. Be vague when answering the client's questions about instructions.
B rationale: Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.
C. Ask the client why he is suspicious of others.
C rationale: Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.
D. Use an overly friendly approach.
D rationale: Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.
Full Explanation
Choice A rationale:
Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.
Choice B rationale:
Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.
Choice C rationale:
Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.
Choice D rationale:
Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.