Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following findings should the nurse expect?
A. Depends on their friends for emotional support.
"Depends on their friends for emotional support.”. While it's common for adolescents to rely on their friends for emotional support, this behavior is not necessarily indicative of a problem. Depending on friends for emotional support can be a healthy part of adolescent development, and it does not specifically relate to the loss of a parent.
B. Clings to their caregiver.
"Clings to their caregiver.”. The correct answer, "Clings to their caregiver," is a common response to the loss of a parent in adolescence. When adolescents experience the death of a parent, they often feel a strong need for emotional support and security. They may cling to their remaining caregiver, seeking comfort and reassurance during this challenging time.
C. Exhibits toileting problems.
"Exhibits toileting problems.”. Exhibiting toileting problems can be a potential response to stress and emotional distress, but it is not the most expected or specific finding when a parent has recently died. This behavior may be more common in younger children who are still developing their coping mechanisms.
D. Reports tightness in their chest.
"Reports tightness in their chest.”. While emotional distress can manifest physically, such as chest tightness, it is not the most characteristic finding when a parent has recently died. Clinging to a caregiver and seeking emotional support are more typical responses in adolescents.
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Full Explanation
Choice A rationale:
"Depends on their friends for emotional support.”. While it's common for adolescents to rely on their friends for emotional support, this behavior is not necessarily indicative of a problem. Depending on friends for emotional support can be a healthy part of adolescent development, and it does not specifically relate to the loss of a parent.
Choice B rationale:
"Clings to their caregiver.”. The correct answer, "Clings to their caregiver," is a common response to the loss of a parent in adolescence. When adolescents experience the death of a parent, they often feel a strong need for emotional support and security. They may cling to their remaining caregiver, seeking comfort and reassurance during this challenging time.
Choice C rationale:
"Exhibits toileting problems.”. Exhibiting toileting problems can be a potential response to stress and emotional distress, but it is not the most expected or specific finding when a parent has recently died. This behavior may be more common in younger children who are still developing their coping mechanisms.
Choice D rationale:
"Reports tightness in their chest.”. While emotional distress can manifest physically, such as chest tightness, it is not the most characteristic finding when a parent has recently died. Clinging to a caregiver and seeking emotional support are more typical responses in adolescents.
Similar Questions
A nurse is teaching a client who has diabetic neuropathy about foot care.
Which of the following instructions should the nurse include?
A. Apply lotion between the toes.
"Apply lotion between the toes.”. Applying lotion between the toes is not a recommended practice for individuals with diabetic neuropathy. The rationale for this is that excess moisture between the toes can create an environment conducive to fungal infections, which individuals with diabetes are more susceptible to due to compromised immune function and poor circulation.
B. Wear open-toed shoes.
"Wear open-toed shoes.”. Wearing open-toed shoes is generally not recommended for individuals with diabetic neuropathy. Open-toed shoes expose the feet to potential injury and do not provide adequate protection. It's essential to wear closed-toed, well-fitting shoes to prevent foot injuries and complications.
C. Avoid walking barefoot.
"Avoid walking barefoot.”. The correct answer, "Avoid walking barefoot," is a crucial instruction for individuals with diabetic neuropathy. Walking barefoot increases the risk of injury, as patients with neuropathy may not feel pain or discomfort from small cuts or injuries to their feet. It is essential to protect the feet by wearing shoes or slippers to minimize the risk of wounds and infections.
D. Wash feet in hot water.
Full Explanation
Choice A rationale:
"Apply lotion between the toes.”. Applying lotion between the toes is not a recommended practice for individuals with diabetic neuropathy. The rationale for this is that excess moisture between the toes can create an environment conducive to fungal infections, which individuals with diabetes are more susceptible to due to compromised immune function and poor circulation.
Choice B rationale:
"Wear open-toed shoes.”. Wearing open-toed shoes is generally not recommended for individuals with diabetic neuropathy. Open-toed shoes expose the feet to potential injury and do not provide adequate protection. It's essential to wear closed-toed, well-fitting shoes to prevent foot injuries and complications.
Choice C rationale:
"Avoid walking barefoot.”. The correct answer, "Avoid walking barefoot," is a crucial instruction for individuals with diabetic neuropathy. Walking barefoot increases the risk of injury, as patients with neuropathy may not feel pain or discomfort from small cuts or injuries to their feet. It is essential to protect the feet by wearing shoes or slippers to minimize the risk of wounds and infections.
Choice D rationale:
A nurse is teaching a client about tactile testing.
Which of the following client statements indicates an understanding of the teaching?
A. "I will be asked to identify different sensations, such as sharp or dull.”.
The client's statement, "I will be asked to identify different sensations, such as sharp or dull," indicates an understanding of the teaching on tactile testing. This choice demonstrates knowledge about the purpose and nature of the test, which involves identifying various sensations, including sharp or dull, to assess the client's sensory perception. The client's response aligns with the expected outcome of the teaching, showing comprehension.
B. "Small needles will be inserted into one of my muscles.”.
The statement, "Small needles will be inserted into one of my muscles," is not an accurate description of tactile testing. Tactile testing typically involves assessing the client's ability to perceive sensations on their skin, such as sharpness, dullness, temperature, or pressure. Inserting needles into muscles is not a part of this test, so this choice does not indicate an understanding of the teaching.
C. "A dye is injected into my vein during this test.”.
The statement, "A dye is injected into my vein during this test," is not related to tactile testing. Tactile testing does not involve injecting dye into veins. This response suggests a misunderstanding of the purpose and procedure of the test, so it is not the correct choice.
D. "I will be asleep during this test.”.
The statement, "I will be asleep during this test," is not consistent with tactile testing. Tactile testing is a sensory assessment that requires the client to be awake and actively participate in identifying sensations. This response indicates a lack of understanding of the test, and it is not the correct choice.
Full Explanation
Choice A rationale:
The client's statement, "I will be asked to identify different sensations, such as sharp or dull," indicates an understanding of the teaching on tactile testing. This choice demonstrates knowledge about the purpose and nature of the test, which involves identifying various sensations, including sharp or dull, to assess the client's sensory perception. The client's response aligns with the expected outcome of the teaching, showing comprehension.
Choice B rationale:
The statement, "Small needles will be inserted into one of my muscles," is not an accurate description of tactile testing. Tactile testing typically involves assessing the client's ability to perceive sensations on their skin, such as sharpness, dullness, temperature, or pressure. Inserting needles into muscles is not a part of this test, so this choice does not indicate an understanding of the teaching.
Choice C rationale:
The statement, "A dye is injected into my vein during this test," is not related to tactile testing. Tactile testing does not involve injecting dye into veins. This response suggests a misunderstanding of the purpose and procedure of the test, so it is not the correct choice.
Choice D rationale:
The statement, "I will be asleep during this test," is not consistent with tactile testing. Tactile testing is a sensory assessment that requires the client to be awake and actively participate in identifying sensations. This response indicates a lack of understanding of the test, and it is not the correct choice.
A nurse is caring for a client who has a terminal diagnosis and states, "If I get better, I promise to go to church every day.”. The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
A. Depression.
The statement, "Depression," does not align with the client's promise to go to church every day if they get better. Depression is one of the Kubler-Ross stages of grief, but it does not reflect the client's behavior of making promises to engage in specific activities if they improve. Therefore, this choice does not represent the client's current stage of grief accurately.
B. Bargaining.
The client's statement, "If I get better, I promise to go to church every day," indicates that the client is in the bargaining stage of grief. During this stage, individuals often make deals or promises in an attempt to reverse or delay the terminal diagnosis or adverse outcome. This response reflects the typical behavior associated with the bargaining stage, making it the correct choice.
C. Denial.
The statement, "Denial," is not consistent with the client's promise to go to church every day. Denial is a stage in which individuals may refuse to accept the reality of their situation and may not engage in making promises or deals. Therefore, this choice does not accurately represent the client's current stage of grief.
D. Anger.
The statement, "Anger," does not align with the client's promise to go to church every day. Anger is another stage of grief, characterized by frustration and resentment, but it does not correspond to the client's behavior of making promises. This choice does not accurately reflect the client's current stage of grief.
Full Explanation
Choice A rationale:
The statement, "Depression," does not align with the client's promise to go to church every day if they get better. Depression is one of the Kubler-Ross stages of grief, but it does not reflect the client's behavior of making promises to engage in specific activities if they improve. Therefore, this choice does not represent the client's current stage of grief accurately.
Choice B rationale:
The client's statement, "If I get better, I promise to go to church every day," indicates that the client is in the bargaining stage of grief. During this stage, individuals often make deals or promises in an attempt to reverse or delay the terminal diagnosis or adverse outcome. This response reflects the typical behavior associated with the bargaining stage, making it the correct choice.
Choice C rationale:
The statement, "Denial," is not consistent with the client's promise to go to church every day. Denial is a stage in which individuals may refuse to accept the reality of their situation and may not engage in making promises or deals. Therefore, this choice does not accurately represent the client's current stage of grief.
Choice D rationale:
The statement, "Anger," does not align with the client's promise to go to church every day. Anger is another stage of grief, characterized by frustration and resentment, but it does not correspond to the client's behavior of making promises. This choice does not accurately reflect the client's current stage of grief.