Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?
A. Initiate one-to-one nursing observation.
Initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.
B. Make a contract with the client for weight gain.
Making a contract with the client for weight gain is not an appropriate first action as it does not address the client's immediate safety concerns.
C. Administer the Hamilton depression scale.
Administering the Hamilton depression scale may be important to assess the client's depressive symptoms but is not the most urgent priority.
D. Review the client's toxicology laboratory report.
Reviewing the client's toxicology laboratory report may be necessary for the overall assessment of the client, but safety comes first.
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
initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.
Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.
Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.
Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.
Similar Questions
A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?
A. The client's attempt to decrease anxiety.
As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.
B. The client's wish to decrease the time available for interaction with others.
The client's wish to decrease the time available for interaction with others is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
C. The client's unconscious need to manipulate others.
The client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
D. The client's delusion that cleaning is necessary.
The client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.
Full Explanation
As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.
Choice B, the client's wish to decrease the time available for interaction with others, is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
Choice D, the client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.
A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?
A. "It sounds like you're having a difficult time."
A) "It sounds like you're having a difficult time": This response is empathetic and acknowledges the client's distress. By validating the client's feelings, the nurse provides support and opens the door for further discussion about their anxiety and related symptoms. This approach can help the client feel understood and encourage them to share more about their experience.
B. "Have you talked to your provider about this yet?"
B) "Have you talked to your provider about this yet?": While it is important for the client to communicate their symptoms to their provider, this response might come across as dismissive of the client's immediate emotional state. It could be more supportive to first acknowledge the client's current experience before suggesting further actions.
C. "Everyone has trouble sleeping at times."
C) "Everyone has trouble sleeping at times": This response may minimize the client's concerns and fail to address their specific experience. It can come off as invalidating by suggesting that their situation is normal and not warranting further exploration or support.
D. "Why do you think you are so anxious?"
D) "Why do you think you are so anxious?": Asking why the client feels anxious might be perceived as interrogative rather than supportive. This approach could put pressure on the client to explain their feelings, which might not be productive if they are struggling to articulate their emotions or causes of anxiety.
Full Explanation
Answer: A. "It sounds like you're having a difficult time."
Rationale:
A) "It sounds like you're having a difficult time":
This response is empathetic and acknowledges the client's distress. By validating the client's feelings, the nurse provides support and opens the door for further discussion about their anxiety and related symptoms. This approach can help the client feel understood and encourage them to share more about their experience.
B) "Have you talked to your provider about this yet?":
While it is important for the client to communicate their symptoms to their provider, this response might come across as dismissive of the client's immediate emotional state. It could be more supportive to first acknowledge the client's current experience before suggesting further actions.
C) "Everyone has trouble sleeping at times":
This response may minimize the client's concerns and fail to address their specific experience. It can come off as invalidating by suggesting that their situation is normal and not warranting further exploration or support.
D) "Why do you think you are so anxious?":
Asking why the client feels anxious might be perceived as interrogative rather than supportive. This approach could put pressure on the client to explain their feelings, which might not be productive if they are struggling to articulate their emotions or causes of anxiety.
A nurse is caring for a client who has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following situations should the nurse administer the alprazolam?
A. The client pretends to be a government agent.
"The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.
B. The client reports seeing bugs crawling on the walls.
"The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.
C. The client describes an increase in pain after receiving meperidine.
"The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.
D. The client reports his heart is beating out of his chest.
"The client reports his heart is beating out of his chest." this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.
Full Explanation
"The client reports his heart is beating out of his chest." as this symptom is consistent with anxiety and the client's prescription is for PRN anxiety. Alprazolam is a medication used to treat anxiety disorders and symptoms of anxiety.
Choice A, "The client pretends to be a government agent," is not a symptom that would be treated with alprazolam.
Choice B, "The client reports seeing bugs crawling on the walls," may indicate the presence of a hallucination or other mental health symptom, but is not related to anxiety and is not an appropriate indication for alprazolam.
Choice C, "The client describes an increase in pain after receiving meperidine," indicates a potential adverse drug effect and is not related to anxiety or an indication for alprazolam.