Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?
A. "Set firm limits and boundaries for the client."
B. “Tell the client that you are going to report to the director of the unit.”
C. "Walk away and have someone else take care of the client."
D. "It happens frequently so just ignore it they will stop."
This question is an excerpt from Nurse Dive's nursing test bank - ATI Mental Health Proctored Exam 1. Take the full exam now
Full Explanation
When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.
the other choices are incorrect:
1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.
2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.
3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.
Similar Questions
Order, digoxin (Lanoxin) 0.25 mg IM daily. Available digoxin (Lanoxin) 0.5 mg/2 mL How many mL will the nurse administer?
Full Explanation
To calculate the amount of mL the nurse should administer, we can use a proportion based on the available concentration of digoxin (Lanoxin) and the prescribed dose.
The available concentration is 0.5 mg/2 mL, which means there are 0.5 mg of digoxin in 2 mL of solution.
The prescribed dose is 0.25 mg.
Now we can set up the proportion:
0.5 mg / 2 mL = 0.25 mg / x mL
Cross-multiplying, we have:
0.5 mg * x mL = 2 mL * 0.25 mg
0.5x = 0.5
Dividing both sides by 0.5, we get:
x = 0.5 / 0.5
x = 1
Therefore, the nurse should administer 1 mL of digoxin (Lanoxin) to deliver a dose of 0.25 mg.
The nurse is performing an admission assessment for a client admitted to the behavioral health unit. Which social/cultural category will the nurse document that may be contributing to the client's degree of mental illness? Select all that apply. (Select All that Apply.)
A. The client reports being unable to find anything meaningful within their life
B. The client attributes life's problems to being without family support.
C. The client is unable to find work and does not have enough money for housing
D. The client states that they are discriminated against due to their country of origin.
E. The client reports not belonging anywhere and is without family support
Full Explanation
The client attributes life's problems to being without family support: Lack of family support can significantly impact an individual's mental health and well-being. It can lead to feelings of isolation, loneliness, and a lack of emotional support, potentially contributing to the development or exacerbation of mental illness.
The client is unable to find work and does not have enough money for housing: Financial instability, unemployment, and inadequate housing are social determinants of mental health. These factors can contribute to stress, anxiety, and a sense of hopelessness, which may impact the client's mental well-being.
The client states that they are discriminated against due to their country of origin: Experiencing discrimination based on one's country of origin can lead to feelings of marginalization, social exclusion, and psychological distress. Discrimination is a social factor that can contribute to the development of mental illness or exacerbate existing mental health conditions.
The client reports not belonging anywhere and is without family support: Feeling a lack of belonging or a sense of disconnectedness can have a negative impact on mental health. It can contribute to feelings of isolation, low self-esteem, and depression. Additionally, lacking family support further compounds the client's sense of not belonging, potentially affecting their mental well-being.
Incorrect:
The client reports being unable to find anything meaningful within their life: While this statement suggests a lack of purpose or fulfillment in the client's life, it does not specifically address social or cultural factors that could contribute to their mental illness. It may be important to explore further during the assessment to identify underlying issues, but it does not fall under the social/cultural category.
Lasix 50 mg IV. The available vial contains 80mg/2ml. What is the dose in ml?
Full Explanation
To calculate the dose of Lasix (furosemide) in milliliters (ml), we can set up a proportion using the available concentration and the prescribed dose.
The available concentration is 80 mg/2 ml, which means there are 80 mg of Lasix in 2 ml of solution.
The prescribed dose is 50 mg.
Setting up the proportion:
80 mg / 2 ml = 50 mg / x ml
Cross-multiplying:
80 mg * x ml = 2 ml * 50 mg
80x = 100
Dividing both sides by 80:
x = 100 / 80
x = 1.25
Therefore, the dose of Lasix 50 mg IV would be approximately 1.25 ml.