Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at a walk in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?
A. Attention-seeking conduct
In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.
B. Wild fidgeting
Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.
C. Threatening behavior
While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.
D. Mild difficulty problem solving
Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.
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Full Explanation
A. In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.
B. Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.
C.While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.
D. Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.
Similar Questions
A nurse is caring for a client who reports an upset stomach after taking chlorpromazine. Which of the following responses should the nurse make?
A. “Taking the medication on an empty stomach will decrease your stomach upset."
This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.
B. "Lie down for 30 minutes after each dose to help prevent stomach upset."
This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.
C. "Talk to your provider about decreasing your dose of medication,"
While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.
D. "Drink a glass of milk with each dose of your medication."
Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.
Full Explanation
A. “Taking the medication on an empty stomach will decrease your stomach upset." This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.
B. “Lie down for 30 minutes after each dose to help prevent stomach upset.” This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.
C. “Talk to your provider about decreasing your dose of medication.” While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.
D. “Drink a glass of milk with each dose of your medication.” Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.
A male nurse is assigned to care for a female client who was admitted to the hospital for treatment of injuries following a domestic abuse incident. The client tells the nurse manager she does not want a male nurse as her caregiver. Which of the following nursing responses should the nurse manager make?
A. I can arrange for a female assistive personnel to do your personal hygiene care."
While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.
B. "Your doctor is a man, so it seems like this should not be a problem."
"Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.
C. I can review the assignments and arrange for a female nurse to care for you."
"Explanation:Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.
D. "The nurse assigned to care for you is very capable and cares for other women in this situation."
"While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.
Full Explanation
While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.
B) "Your doctor is a man, so it seems like this should not be a problem."
Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.
C) "I can review the assignments and arrange for a female nurse to care for you."
Explanation:
Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.
D) "The nurse assigned to care for you is very capable and cares for other women in this situation."
While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
A. Encouraging client feedback about satisfaction with the facility experience
Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.
B. Explaining unit rules and policies regarding unacceptable behaviors
Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.
C. Supporting the client's wish to refuse prescribed medications
Explanation:Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.
D. Making sure the client understands expectations for client participation
Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.
Full Explanation
Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.
B) Explaining unit rules and policies regarding unacceptable behaviors:
Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.
C) Supporting the client's wish to refuse prescribed medications.
Explanation:
Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.
D) Making sure the client understands expectations for client participation:
Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.