Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse caring for a client who has depression observes the client coming to breakfast freshly bathed, wearing clean clothes, and with combed and styled hair. Which of the following responses by the nurse is therapeutic?
A. "Everyone feels better after showering.".
"Everyone feels better after showering." Rationale: This response minimizes the client's efforts and feelings. Depression can often make even simple tasks like showering feel daunting, so this response doesn't acknowledge the client's achievement appropriately.
B. "Why are you all dressed up today? Is it a special occasion?".
"Why are you all dressed up today? Is it a special occasion?" Rationale: This response implies that there must be a special reason for the client's improved appearance. It could inadvertently put pressure on the client to come up with a justification for their self-care, potentially causing discomfort.
C. "You must be getting better. You look great!".
"You must be getting better. You look great!" Rationale: This response acknowledges the client's efforts and highlights their positive change. It offers encouragement and support without assuming or questioning motives. It's a positive reinforcement that can help boost the client's self-esteem.
D. "I see you have done some grooming today.".
"I see you have done some grooming today." Rationale: While this response acknowledges the client's grooming, it lacks the positive and affirming tone of choice C. It focuses on the observation rather than expressing encouragement or recognition for the client's progress.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Similar Questions
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?
A. "My child was born with a birth defect due to an exposure I had overseas.".
"My child was born with a birth defect due to an exposure I had overseas." Rationale: This statement doesn't directly relate to the symptoms of posttraumatic stress disorder (PTSD) such as re-experiencing trauma, hyperarousal, and avoidance behaviors. It might be related to guilt or remorse but doesn't fit the profile of PTSD.
B. "I killed four enemy soldiers with my bare hands and saved my entire battalion.".
"I killed four enemy soldiers with my bare hands and saved my entire battalion." Rationale: While this statement suggests exposure to combat and a traumatic event, it lacks the hallmark symptoms of PTSD. It might indicate desensitization to violence, but it doesn't necessarily reflect the intrusive thoughts and hyperarousal commonly seen in PTSD.
C. "I check any room I enter because the enemy is still after me and could be hiding anywhere.".
"I check any room I enter because the enemy is still after me and could be hiding anywhere." Rationale: This statement reflects hyperarousal, hypervigilance, and re-experiencing symptoms characteristic of PTSD. The client's behavior of checking rooms for threats demonstrates a persistent sense of danger and vigilance even in safe environments.
D. "In my dreams, all I can see are the wounded reaching out and trying to grab me.".
A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After showing the client to his room, which of the following nursing actions is most therapeutic at this time?
A. Medicate the client with a sedative.
"Medicate the client with a sedative." Rationale: Medicating the client immediately with a sedative might provide short-term relief, but it doesn't address the underlying anxiety or promote coping strategies. Using medication as the first response can also create dependence and hinder the development of healthy coping mechanisms.
B. Suggest that the client rest in bed.
"Suggest that the client rest in bed." Rationale: Suggesting rest in bed might not be the most appropriate action for someone with panic-level anxiety. It could lead to rumination and increased anxiety while alone. Direct interventions are generally more effective in managing acute anxiety.
C. Have the client join a therapy group.
"Have the client join a therapy group." Rationale: While therapy groups can be beneficial, they might overwhelm the client in an acute state of panic-level anxiety. The client's ability to engage in a group setting could be compromised at this moment.
D. Remain with the client for a while.
"Remain with the client for a while." Rationale: This choice provides immediate support and reassurance to the client. Presence and active listening from the nurse can help calm the client's anxiety and create a sense of safety. Once the acute anxiety subsides, other interventions like therapy groups can be explored.
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?
A. "You have a great deal to live for.".
This response may seem dismissive and invalidating to the client's feelings of worthlessness. While it's true that the client might have positive aspects in their life, this response does not address the client's emotional pain or provide an opportunity for them to express their feelings.
B. "Why do you feel you are worthless?".
Asking "why" is non-therapeutic; it can feel judgmental and puts the client on the defensive instead of encouraging expression.
C. "It's not unusual for depressed people to feel that way.".
While this statement is true, it might come across as dismissive or minimizing the client's feelings. It's important to acknowledge the client's emotions and provide them with an opportunity to express themselves rather than generalizing their feelings as common for all depressed individuals.
D. "You've been feeling that your life has no meaning.".
This is restating and reflecting feelings, which shows understanding, validates the client’s emotions, and encourages further discussion. It’s the most therapeutic response.