Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about her ability to afford and care for her baby. Which of the following actions should the nurse take?
A. Contact the adolescent’s parent for assistance.
wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
B. Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
C. Refer the adolescent to a local mental health clinic.
is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging. The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
D. Advise the adolescent to place the newborn for adoption.
is wrong because advising the adolescent to place the newborn for
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is B.
Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client, but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.
Similar Questions
A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent.
Which of the following risk factors should the nurse include as the best predictor of future violence?
A. A history of being in prison.
is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
B. Previous violent behavior.
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors. Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
C. Experiencing delusions.
wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved
D. Male gender.
is wrong because experiencing delusions is not necessarily associated with violence, unless they are of a paranoid or persecutory nature. Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal
Full Explanation
The correct answer is B.
Previous violent behavior. According to the web search results, this is the best predictor of future violence among the given risk factors.
Other risk factors include past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).
Choice A is wrong because a history of being in prison is not a direct cause of violence, but rather a possible consequence of it.
Choice C is wrong because male gender is not a sufficient factor to predict violence, as there are many other variables involved. Choice D is wrong because experiencing delusions is not necessarily associated with violence, unless they are of a paranoid or persecutory nature.
Normal ranges for violence risk assessment are not standardized, but some tools that can be used include the Historical Clinical Risk Management-20 (HCR-20), the Violence Risk Appraisal Guide (VRAG), and the Psychopathy Checklist-Revised (PCL-R). These tools use different scales and criteria to evaluate the likelihood of violent behavior in individuals.
A nurse in an emergency department is caring for a client.
A nurse in an outpatient orthopedic clinic is caring for the client six weeks following surgical repair of a fractured radius. Which of the following information provided by the client indicates improvement?
Select all that apply.
A. The client has gained 1.8 kg (4 lb). BMI is 18.9.
This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.
B. The clients adult child prepares two meals per day for the client.
This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.
C. The clients clothing is clean and appropriate for the weather.
The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.
D. The client receives three baths per week from a home care aide.
The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.
E. The client reports frequent toothaches and lack of dental care.
The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.
F. The client makes eye contact and smiles when speaking.
The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.
Full Explanation
Answer is… C and F indicate improvement.
A The client has gained 1.8 kg (4 lb). BMI is 18.9. This is not an improvement because the client’s BMI is still below the normal range of 18.5 to 24.9 The client may have malnutrition or other health problems that affect their weight.
B The clients adult child prepares two meals per day for the client. This is not an improvement because it shows that the client still depends on others for their basic needs and may have difficulty with self-care.
C The clients clothing is clean and appropriate for the weather. This is an improvement because it shows that the client has good hygiene and can dress themselves appropriately.
D The client receives three baths per week from a home care aide. This is not an improvement because it shows that the client still needs assistance with bathing and may have limited mobility or pain.
E The client reports frequent toothaches and lack of dental care. This is not an improvement because it shows that the client has poor oral health and may have infections or other complications.
F The client makes eye contact and smiles when speaking. This is an improvement because it shows that the client has positive mood and social interaction.
: https://www.hopkinsmedicine.org/health/conditions-and-diseases/distal-radius-fracture- wrist-fracture : https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
A nurse in an emergency department is caring for a client. Nurses' Notes.
1200:.
Client is an 82-year-old male who presents with his adult child for evaluation of right arm pain after a fall. Client noted to have several superficial abrasions on right forearm and elbow. Also has numerous bruises in various stages of healing on arms and upper chest. Client rates pain in right lower forearm an 8 on a 0 to 10 pain scale and is not moving the arm.
1210:.
Client noted to keep head down and makes limited eye contact. Speaks very softly and looks at adult child before answering interview questions. Has strong body odor and clothes are unclean. Client's adult child answers most questions. Client grimacing and guarding right arm.
Client weighed, is 56.2 kg (124 lb) and 175 cm (69 in) tall. BMI 18.3.
1230:.
Client's adult child left facility to go home and get the client’s prescribed medications. Client visibly more relaxed and now speaking more openly to staff with improved eye contact. Client reports that he has lived with his adult child for the past several.
Vital Signs. 1200:.
Temperature 36.7° C (98° F). Heart rate 96/min.
Blood pressure 142/96 mm Hg. Respiratory rate 16/min.
SpO2 97% on room air.
The nurse is preparing to speak to the facility's Social Worker about the client's condition.
Select the 5 findings the nurse should plan to include in the report.
A. ECG results.
This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.
B. Client's report of lack of food in home.
This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
C. client's report of lack of access to bank accounts.
This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
D. Clients avoidance of eye contact.
This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
E. Clients report of weight loss.
This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
F. Numerous bruises in various stages of healing.
This may indicate physical abuse by the adult child who is hitting or injuring the client.
Full Explanation
Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.
- B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
- C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
- D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
- E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
- F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.
A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.
Normal ranges for vital signs:.
- Temperature: 36.1°C to 37.2°C (97°F to 99°F).
- Heart rate: 60 to 100 beats per minute.
- Blood pressure: less than 120/80 mm Hg.
- Respiratory rate: 12 to 20 breaths per minute.
- SpO2: 95% to 100% on room air. Table for BMI categories:
|
BMI |
Weight Status |
|
Below 18.5 |
Underweight |
|
18.5 to 24.9 |
Normal |
|
25.0 to 29.9 |
Overweight |
|
30.0 and above |
Obese |
The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.