Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die."
Which of the following responses should the nurse make?
A. "I'm sure your family does not want you to die."
"I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
B. "Why would you believe such things?"
"Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
C. "How does this make you feel?"
"How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
D. "You should talk to your family about your feelings."
"You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
"How does this make you feel?"
- A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
- B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
- C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
- D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
Similar Questions
A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?
A. Form a committee of staff members to investigate current staffing issues
Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. By forming a committee, the nurse manager can gather different perspectives and insights from the staff members who are directly affected by the staffing issues. This will help in identifying the specific problems and coming up with effective solutions. Furthermore, involving the staff in the decision-making process can increase their acceptance of the changes and reduce resistance.
B. Provide support to staff members who are resistant to staffing changes
Providing support to staff members who are resistant to staffing changes is an important step, but it should not be the first action. Before providing support, the nurse manager needs to understand the specific issues causing the resistance. This can be achieved by forming a committee of staff members to investigate the staffing issues.
C. Schedule a staff meeting to present the different options to staff members
Scheduling a staff meeting to present the different options to staff members is a crucial step in the process. However, this should be done after the nurse manager has a clear understanding of the staffing issues and has identified potential solutions. Presenting options without first understanding the problem may lead to ineffective solutions and increased resistance from staff members.
D. Give the staff members advance written notice of staffing changes
Giving the staff members advance written notice of staffing changes is a necessary step to ensure transparency and to give staff members time to adjust. However, this should be done after the nurse manager has identified the staffing issues, explored potential solutions, and decided on the changes to be implemented.
Full Explanation
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The correct answer is Choice A.
Choice A rationale: Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. By forming a committee, the nurse manager can gather different perspectives and insights from the staff members who are directly affected by the staffing issues. This will help in identifying the specific problems and coming up with effective solutions. Furthermore, involving the staff in the decision-making process can increase their acceptance of the changes and reduce resistance.
Choice B rationale: Providing support to staff members who are resistant to staffing changes is an important step, but it should not be the first action. Before providing support, the nurse manager needs to understand the specific issues causing the resistance. This can be achieved by forming a committee of staff members to investigate the staffing issues.
Choice C rationale: Scheduling a staff meeting to present the different options to staff members is a crucial step in the process. However, this should be done after the nurse manager has a clear understanding of the staffing issues and has identified potential solutions. Presenting options without first understanding the problem may lead to ineffective solutions and increased resistance from staff members.
Choice D rationale: Giving the staff members advance written notice of staffing changes is a necessary step to ensure transparency and to give staff members time to adjust. However, this should be done after the nurse manager has identified the staffing issues, explored potential solutions, and decided on the changes to be implemented.
A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
A. Palpate the degree of edema.
Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP.
B. Regulate IV pump fluid rate.
Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.
C. Measure the client's daily weight.
Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.
D. Assess the client's vital signs.
Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.
Full Explanation
- A. Palpate the degree of edema. This is incorrect because palpating the degree of edema requires clinical judgment and skill, which are beyond the scope of practice of an AP. -
B. Regulate IV pump fluid rate. This is incorrect because regulating IV pump fluid rate is a nursing responsibility that involves calculating and adjusting the infusion rate based on the client's condition and orders.
- C. Measure the client's daily weight. This is correct because measuring the client's daily weight is a routine task that can be delegated to an AP, as long as the nurse provides clear instructions and monitors the results. The client's daily weight is an indicator of fluid balance and can help evaluate the effectiveness of treatment.
- D. Assess the client's vital signs. This is incorrect because assessing the client's vital signs requires interpretation and analysis of data, which are nursing functions that cannot be delegated to an AP.
A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?
A. "I'm sure your family does not want you to die."
Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
B. "Why would you believe such things?"
Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
C. "How does this make you feel?"
Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
D. "You should talk to your family about your feelings."
Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.
Full Explanation
How does this make you feel?
- A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
- B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
- C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
- D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.