Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is admitting a client who has schizophrenia.
The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?
A. “Have you taken your medication today?”.
The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental
B. “How long have you been hearing the voices?”.
The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time
C. “What are the voices telling you?”.
The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.
D. “I realize the voices are real to you, but I don’t hear anything.”.
The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation
E. undefined
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 choice C. The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.
The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental (choice A).
The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).
The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).
The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.
Similar Questions
A nurse is assessing a 2-year-old toddler.
Which of the following findings should the nurse expect?
A. Nontender, protruding abdomen.
A nontender, protruding abdomen is a normal finding for a 2year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.
B. Head circumference exceeds chest circumference.
because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.
C. Palpable fontanels.
fontanels, or soft spots on the skull, should be closed by age 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.
D. Natural loss of deciduous teeth
because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.
E. undefined
Full Explanation
Answer and explanation.
The correct answer is choice A. A nontender, protruding abdomen is a normal finding for a 2year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.
Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.
Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by age 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.
Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.
A nurse is caring for a client who has experienced a stroke and is moving in with their adult child.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
A. Implement firm but flexible boundaries in their relationship.
. Implement firm but flexible boundaries in their relationship. This is because boundaries can help the client and family to respect each other’s roles, needs and preferences, and to avoid role confusion, resentment or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
B. Minimize open discussion regarding the changes to avoid embarrassment.
minimizing open discussion regarding the changes can lead to misunderstanding, frustration or isolation. The client and family should communicate openly and honestly about their feelings, expectations and challenges, and seek support when needed.
C. Encourage authoritative communication from the adult child.
because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
D. Decrease socialization with extended relatives until roles are identified.
decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
E. undefined
Full Explanation
The correct answer is choice A. Implement firm but flexible boundaries in their relationship.
This is because boundaries can help the client and family to respect each other’s roles, needs and preferences, and to avoid role confusion, resentment or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration or isolation. The client and family should communicate openly and honestly about their feelings, expectations and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care.
Which of the following instructions should the nurse include in the teaching?
A. Soak feet twice daily.
because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
B. Wear clean cotton socks every day.
Wear clean cotton socks every day. This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
C. Round the edges of toenails when trimming.
rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
D. Use moisturizing lotion between the toes.
is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
E. undefined
Full Explanation
The correct answer is choice B. Wear clean cotton socks every day.
This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
Choice A is wrong because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
Choice C is wrong because rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
Choice D is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
Some other foot care guidelines for people with diabetes are:
- Inspect your feet daily and look for signs of injury, such as scrapes, cuts, blisters, etc.
- Wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in.
- Don’t walk barefoot.
Protect your feet from heat and cold. Wear appropriate fitting shoes to avoid injury and blisters.
- See a doctor to remove corns or calluses (don’t do it yourself). Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers.
- Don’t sit with your legs crossed or stand in one position for long periods of time.
- See your doctor regularly for foot exams and report any problems or changes in your feet.
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