Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
A. Teach the client to develop a plan for daily structured activities.
rationale: Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.
B. Encourage the client to exercise.
rationale: Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.
C. Suggest that the client develop a list of pleasurable activities.
rationale: Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.
D. Provide education on methods to enhance sleep.
rationale: Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.
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Full Explanation
Choice A rationale:
Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.
Choice B rationale:
Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.
Choice C rationale:
Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.
Choice D rationale:
Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.
Similar Questions
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
A. Compromised family coping.
rationale: Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.
B. Ineffective sexual patterns.
rationale: Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.
C. Impaired environmental interpretation.
rationale: Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.
D. Disturbed sensory perception.
rationale: The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.
Full Explanation
Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.
Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.
Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.
Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.
The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
A. Encourage the mother to write thoughts and feelings in a journal.
Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Determine if the mother has other children who do not have developmental disabilities.
Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassure the mother that her child will achieve some growth and development milestones.
Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Ask the mother if she has ever thought about harming herself or her child.
Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.
Full Explanation
A. Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
A. Assist the client with relaxation techniques in the group.
Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.
B. Escort the client from the group to reduce stimuli.
Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.
C. Provide education about ways to cope with anxiety.
Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.
D. Ask the client to describe and identify the source of the feelings.
Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.
Full Explanation
A. Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.
B. Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.
C. Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.
D. Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.