Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?
A. Place the client in a private room.
Placing the client in a private room does not address the client’s physical needs.
B. Determine the client's level of disorientation.
Determining the client's level of disorientation is something necessary to assess but not the priority.
C. Pad the side rails of the bed with towels.
Padding the side rails of the bed with towels is not the priority intervention, and contributes little to the prevention of falls.
D. Accompany the client when ambulating.
The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.
Choice A, placing the client in a private room, does not address the client’s physical needs.
Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.
Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.
Similar Questions
A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?
A. "Aren't you excited about being discharged today?"
"Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.
B. "How do you feel about being discharged?"
"How do you feel about being discharged?" is not the best response because it is too broad.
C. "I will send you a note in a few weeks."
"I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.
D. "I know you will do well living out in the community."
"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. This Choice, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.
Full Explanation
"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.
Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.
Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.
Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.
A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?
A. Identify the use of defense mechanisms.
Identifying the use of defense mechanisms is an important aspect of treatment but can be addressed later.
B. Prevent the client from harming herself or others.
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
C. Support the client's coping skills.
Supporting the client's coping skills is not a priority intervention.
Full Explanation
Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.
Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.
Choice C, supporting the client's coping skills, is not a priority intervention.
A nurse is discussing insomnia management techniques with a group of clients who have anxiety disorders. Which of the following techniques mentioned by a client requires further teaching?
A. "If I wake up at night, I go to another room and read for 20 minutes."
"If I wake up at night, I go to another room and read for 20 minutes" - This is a good sleep hygiene habit.
B. "I eat my evening meal at least 3 hours before I go to bed."
"I eat my evening meal at least 3 hours before I go to bed" - This is a good sleep hygiene habit
C. "I watch the television in my bedroom to help me sleep."
"I watch the television in my bedroom to help me sleep." This technique requires further teaching as watching TV before sleep is a poor sleep hygiene habit. Clients should be advised to keep TVs, mobile phones, and other electronic devices out of the bedroom, as electronic devices can be a source of stimulation and disrupt a sleep routine. Adequate sleep hygiene techniques include going to bed and waking up at the same time every day, avoiding caffeine, nicotine, and alcohol, and engaging in physical activity early in the day. Reading for a few minutes or engaging in some other relaxing activity can reduce difficulty falling back to sleep.
D. "I have stopped taking naps in the afternoon."
"I have stopped taking naps in the afternoon" - This is a good sleep hygiene habit Each of the other options helps with good sleep hygiene but C will not help.
Full Explanation
"I watch the television in my bedroom to help me sleep." This technique requires further teaching as watching TV before sleep is a poor sleep hygiene habit. Clients should be advised to keep TVs, mobile phones, and other electronic devices out of the bedroom, as electronic devices can be a source of stimulation and disrupt a sleep routine. Adequate sleep hygiene techniques include going to bed and waking up at the same time every day, avoiding caffeine, nicotine, and alcohol, and engaging in physical activity early in the day. Reading for a few minutes or engaging in some other relaxing activity can reduce difficulty falling back to sleep.
Option A: "If I wake up at night, I go to another room and read for 20 minutes" - This is a good sleep hygiene habit
Option B: "I eat my evening meal at least 3 hours before I go to bed" - This is a good sleep hygiene habit Option D: "I have stopped taking naps in the afternoon" - This is a good sleep hygiene habit Each of the other options helps with good sleep hygiene but C will not help.