Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?
A. Give the client a schedule of planned daily activities.
Correct- this can help them structure their time, reduce boredom and anxiety, and increase their sense of control and achievement. This can also foster social interaction and engagement with the staff and peers. A schedule of planned daily activities is consistent with the principles of psychosocial rehabilitation, which is an evidence-based approach for people with schizophrenia.
B. Engage the client in a game of cards.
Incorrect- this may be too challenging or stressful for the client, especially if they have cognitive impairments or negative symptoms.
C. Encourage the client to have lunch off the unit.
Incorrect- may expose them to unfamiliar or unpredictable situations that could trigger or worsen their psychotic symptoms.
D. Complete an assessment of social support.
Incorrect- it is not an intervention that directly addresses the client's current problem of social isolation.
This question is an excerpt from Nurse Dive's nursing test bank - RN Hesi Exit Proctored Exam. Take the full exam now
Full Explanation
A) Correct- this can help them structure their time, reduce boredom and anxiety, and increase their sense of control and achievement. This can also foster social interaction and engagement with the staff and peers. A schedule of planned daily activities is consistent with the principles of psychosocial rehabilitation, which is an evidence-based approach for people with schizophrenia.
B) Incorrect- this may be too challenging or stressful for the client, especially if they have cognitive impairments or negative symptoms.
C) Incorrect- may expose them to unfamiliar or unpredictable situations that could trigger or worsen their psychotic symptoms.
D) Incorrect- it is not an intervention that directly addresses the client's current problem of social isolation.
Similar Questions
The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)
Full Explanation
rate (mL/h) = volume (mL) / time (h).
In this case, the volume is 500 mL and the time is 0.5 h (30 minutes).
Plugging these values into the formula, we get: rate (mL/h) = 500 mL / 0.5 h = 1000 mL/h. Therefore, the nurse should set the infusion pump to 1000 mL/hour.
When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?
A. Review transcutaneous bilirubin levels with a bilirubinometer.
Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B. Observe and palpate newborn's breast tissue for enlargement.
Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C. Assess for signs of fluid retention and bilateral pedal edema.
Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D. Explain to mother that the finding is due to increased androgen.
Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.
Full Explanation
A) Incorrect- Reviewing transcutaneous bilirubin levels is unrelated to the presence of an enlarged clitoris. Bilirubin levels are typically assessed to monitor jaundice in newborns.
B) Incorrect- Observing and palpating breast tissue for enlargement is not relevant to the condition of salt-wasting congenital adrenal hyperplasia. Breast tissue enlargement would not be associated with this hormonal disorder.
C) Incorrect- Assessing for signs of fluid retention and bilateral pedal edema is important for monitoring for other conditions, but it is not relevant to the enlarged clitoris seen in this specific scenario.
D) Correct- Salt-wasting congenital adrenal hyperplasia is a genetic disorder that results in a deficiency of certain enzymes required for cortisol and aldosterone production. This deficiency leads to an overproduction of androgens, which can cause virilization of female external genitalia. The enlarged clitoris is a result of increased androgen levels. Explaining this finding to the mother provides her with accurate information about the condition and its effects on the infant's anatomy.
Review H and P.
What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.
A. The amount of time the child was submerged
Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B. Temperature of water
Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C. Whether or not anyone witnessed the fall into the pool
Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D. Oxygen concentration of the ambient air
Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E. The weight of the child
Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.
Full Explanation
A) Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B) Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C) Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D) Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E) Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.