Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client following reported physical abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take?
A. Display disapproval toward the perpetrator.
"Display disapproval toward the perpetrator" - Not appropriate for the clinical setting
B. Probe the client to offer a factual account of the abuse.
"Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting
C. Be direct and honest when communicating with the client.
"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.
D. Invite a family member to be present for the nursing history.
"Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.
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
"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.
Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting
Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting
Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.
Similar Questions
A nurse in an urgent care clinic is caring for a client who is using loud and rapid speech and continuously repeats, "I don't know why my wife left me." Which of the following levels of anxiety is the client experiencing?
A. Moderate
According to the Mayo Clinic moderate anxiety is characterized by symptoms such as loud and rapid speech, difficulty concentrating, restlessness, and increased worry. The client's behavior matches these symptoms, indicating that they are experiencing moderate anxiety.
B. Panic
Panic is incorrect because panic is a severe form of anxiety that involves symptoms such as chest pain, shortness of breath, trembling, and a sense of impending doom. The client does not exhibit these symptoms.
C. Severe
Severe is incorrect because severe anxiety is marked by symptoms such as irrational fear, detachment from reality, hallucinations, and loss of control¹². The client does not show these symptoms.
D. Mild
Mild is incorrect because mild anxiety is associated with symptoms such as nervousness, increased alertness, and slight discomfort¹². The client's symptoms are more intense than mild anxiety.
Full Explanation
Moderate. According to the Mayo Clinic moderate anxiety is characterized by symptoms such as loud and rapid speech, difficulty concentrating, restlessness, and increased worry. The client's behavior matches these symptoms, indicating that they are experiencing moderate anxiety.
Choice B. Panic is incorrect because panic is a severe form of anxiety that involves symptoms such as chest pain, shortness of breath, trembling, and a sense of impending doom. The client does not exhibit these symptoms.
Choice C. Severe is incorrect because severe anxiety is marked by symptoms such as irrational fear, detachment from reality, hallucinations, and loss of control¹². The client does not show these symptoms.
Choice D. Mild is incorrect because mild anxiety is associated with symptoms such as nervousness, increased alertness, and slight discomfort¹². The client's symptoms are more intense than mild anxiety.
A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?
A. The client talks constantly about the traumatic experience.
The client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.
B. The client is constantly drowsy and sleeps 11-12 hr daily.
The client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.
C. The client reports satisfying personal relationships with family and close friends.
The client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.
D. The client is easily startled by loud voices.
The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.
Full Explanation
The client is easily startled by loud voices. Clients with posttraumatic stress disorder (PTSD) may exhibit hyperarousal symptoms, including exaggerated startle responses and hypervigilance. The client talking constantly about the traumatic experience is a possible finding in PTSD but not specific. The client is constantly drowsy and sleeping 11-12 hours daily is more associated with depression than PTSD. While the client may have satisfying personal relationships, it does not address the question of what finding to expect with PTSD, making choice C incorrect.
Reasons why the other choices are not answers:
Choice A, the client talking constantly about the traumatic experience, is a possible symptom of PTSD, but it is not specific to the disorder and may also indicate other disorders.
Choice B, the client being constantly drowsy and sleeping 11-12 hours daily, is more indicative of depression than PTSD and also does not address the question of finding expected with PTSD.
Choice C, the client reports satisfying personal relationships with family and close friends, does not address what finding is expected with PTSD, making it an incorrect answer.
Which statement by the client indicates an understanding of the information provided about sertraline?
A. "I should call the provider if I experience excessive sweating and muscle twitching."
Sertraline is a medication used to treat depression and other mental health conditions that can cause unwanted side effects. Excessive sweating and muscle twitching are potential side effects that should be immediately reported to the healthcare provider. A dry cough is a common side effect of other medications and not specific to sertraline. Decreasing sodium intake is not necessarily related to the medication, and harmless, temporary changes in the ability to taste and smell are not significant enough to warrant special mention.
B. "This medication can cause a dry cough."
"This medication can cause a dry cough," is a potential side effect of other medications and may cause confusion as to what medication the client is taking.
C. "I need to decrease my sodium intake while on this medication."
"I need to decrease my sodium intake while on this medication," is not likely a statement related to sertraline but to other medications or medical conditions.
D. "This medication can cause harmless, temporary changes to my ability to taste and smell."
"This medication can cause harmless, temporary changes to my ability to taste and smell," while accurate, is not the most critical information for the client to know about and may cause confusion as to what the client should report to the provider.
Full Explanation
Sertraline is a medication used to treat depression and other mental health conditions that can cause unwanted side effects. Excessive sweating and muscle twitching are potential side effects that should be immediately reported to the healthcare provider. A dry cough is a common side effect of other medications and not specific to sertraline.
Decreasing sodium intake is not necessarily related to the medication, and harmless, temporary changes in the ability to taste and smell are not significant enough to warrant special mention.
Choice B, "This medication can cause a dry cough," is a potential side effect of other medications and may cause confusion as to what medication the client is taking.
Choice C, "I need to decrease my sodium intake while on this medication," is not likely a statement related to sertraline but to other medications or medical conditions.
Choice D, "This medication can cause harmless, temporary changes to my ability to taste and smell," while accurate, is not the most critical information for the client to know about and may cause confusion as to what the client should report to the provider.