Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?
A. "Are you thinking of harming yourself?"
This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.
B. "Do you really think your family would be better off without you?"
While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.
C. "When did you first start feeling this way?"
While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.
D. "Tell me what is happening right now."
This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.
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Full Explanation
A. "Are you thinking of harming yourself?": Correct
This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.
B. "Do you really think your family would be better off without you?": Incorrect
While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.
C. "When did you first start feeling this way?": Incorrect
While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.
D. "Tell me what is happening right now.": Incorrect
This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.
Similar Questions
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).
A. Female gender
While the risk of attempted suicide is generally higher in females, completed suicide rates are higher in males. Therefore, being female is not typically considered a primary risk factor for suicide, though it's important to note that both genders require attention for prevention.
B. Currently married
Being married is generally considered a protective factor against suicide. Social support and close relationships tend to reduce the risk of suicidal behavior.
C. Age greater than 45 years old
Suicide risk tends to increase with age, particularly for men. Individuals over 45, especially those facing chronic illness, social isolation, or significant life changes, are at higher risk.
D. Substance use disorder
Substance use disorder is a significant risk factor for suicide. Substance abuse can contribute to feelings of hopelessness and despair, impair judgment, and lower inhibitions, increasing the likelihood of suicidal behavior.
E. Schizophrenia: Correct
Schizophrenia is a mental disorder associated with an increased risk of suicide. The symptoms of schizophrenia, such as hallucinations, delusions, and feelings of isolation, can contribute to severe distress and increase the risk of suicidal ideation and behaviors.
Full Explanation
A. Female gender: Incorrect
While the risk of attempted suicide is generally higher in females, completed suicide rates are higher in males. Therefore, being female is not typically considered a primary risk factor for suicide, though it's important to note that both genders require attention for prevention.
B. Currently married: Incorrect
Being married is generally considered a protective factor against suicide. Social support and close relationships tend to reduce the risk of suicidal behavior.
C. Age greater than 45 years old: correct
Suicide risk tends to increase with age, particularly for men. Individuals over 45, especially those facing chronic illness, social isolation, or significant life changes, are at higher risk.
D. Substance use disorder: Correct
Substance use disorder is a significant risk factor for suicide. Substance abuse can contribute to feelings of hopelessness and despair, impair judgment, and lower inhibitions, increasing the likelihood of suicidal behavior.
E. Schizophrenia: Correct
Schizophrenia is a mental disorder associated with an increased risk of suicide. The symptoms of schizophrenia, such as hallucinations, delusions, and feelings of isolation, can contribute to severe distress and increase the risk of suicidal ideation and behaviors.
A nurse is caring for a client who is prescribed tetracycline 2 grams daily PO in four divided doses every 6 hr. Available is tetracycline 250 mg capsules. How many capsules should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the number of capsules that the nurse should administer per dose, the nurse should first divide the total daily dose of tetracycline by the number of doses per day. This gives the dose per administration:
2 grams / 4 doses = 0.5 grams per dose
Next, the nurse should convert the dose from grams to milligrams, since the available capsules are in milligrams. There are 1000 milligrams in one gram, so the nurse should multiply the dose by 1000:
0.5 grams x 1000 mg/g = 500 mg per dose
Finally, the nurse should divide the dose in milligrams by the strength of each capsule, which is 250 mg. This gives the number of capsules that the nurse should administer per dose:
500 mg / 250 mg/capsule = 2 capsules per dose
Therefore, the nurse should administer 2 capsules of tetracycline every 6 hours to the client.
A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?
A. Tactile hallucination
Tactile hallucinations involve false sensations of touch, such as feeling something on the skin that isn't there. While these hallucinations can be distressing, they are not typically considered a priority over other types of hallucinations, especially those that might pose more immediate risks.
B. Command hallucination
Command hallucinations involve hearing voices that command the individual to take specific actions, often harmful ones. These types of hallucinations are considered a significant priority because they can lead to dangerous behaviors, self-harm, or harm to others. Addressing and managing command hallucinations promptly is crucial to ensure the safety of the individual and those around them
C. Visual hallucination
Visual hallucinations involve seeing things that aren't actually present. While these can be distressing, they are generally considered less urgent compared to command hallucinations, which can directly lead to risky actions.
D. Gustatory hallucination
Gustatory hallucinations involve false perceptions of taste. While these can be unsettling, they are not typically considered a priority over command hallucinations, which have a more immediate potential for harm.
Full Explanation
A. Tactile hallucination: Incorrect
Tactile hallucinations involve false sensations of touch, such as feeling something on the skin that isn't there. While these hallucinations can be distressing, they are not typically considered a priority over other types of hallucinations, especially those that might pose more immediate risks.
B. Command hallucination: Correct
Command hallucinations involve hearing voices that command the individual to take specific actions, often harmful ones. These types of hallucinations are considered a significant priority because they can lead to dangerous behaviors, self-harm, or harm to others. Addressing and managing command hallucinations promptly is crucial to ensure the safety of the individual and those around them.
C. Visual hallucination: Incorrect
Visual hallucinations involve seeing things that aren't actually present. While these can be distressing, they are generally considered less urgent compared to command hallucinations, which can directly lead to risky actions.
D. Gustatory hallucination: Incorrect
Gustatory hallucinations involve false perceptions of taste. While these can be unsettling, they are not typically considered a priority over command hallucinations, which have a more immediate potential for harm.