Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client in a clinic.
Exhibit 1 Exhibit 2.
Nurses' Notes.
0900:
A16-year-old client reports to the clinic with their caregiver. The client's caregiver informs the nurse that the client has "not been themselves lately." The client's parents and a sibling passed away from injuries sustained when a tornado moved through their town 1 month ago. They were the only survivor and witnessed their family's deaths.
0910:.
Client appears anxious but answers questions appropriately for age. They report experiencing nightmares that awaken them at night and startle easily during thunderstorm, but the client admits that they have always been afraid of thunderstorms. Client admits smoking marijuana for about 1 month because it helps clear their mind. They also admit that they have no desire to leave the house. They do attend school regularly and are on the honor roll.
Vital Signs.
0915:
Temperature 36.7° C (98° F).
BP 122/80 mm Hg Respiratory rate 20/min Heart rate 99/min.
Based on the information in the client's medical record, which of the following findings require immediate follow-up?
Select the 4 findings that require follow-up.
A. BP 122/80 mmHg.
BP 122/80 mmHg. This is not a finding that requires immediate follow-up because it is within the normal range for a 16-year-old client, which is 110 to 120/70 to 80 mmHg. A normal blood pressure indicates that the client’s cardiovascular system is functioning well and there are no signs of hypertension or hypotension.
B. Heart rate 99/min.
Heart rate 99/min. This is a finding that requires immediate follow-up because it is above the normal range for a 16-year-old client, which is 60 to 100 beats per minute. A high heart rate could indicate anxiety, stress, pain, infection or other conditions that need to be addressed.
C. Startles easy during thunderstorm.
Startles easy during thunderstorm. This is not a finding that requires immediate follow-up because it is a normal reaction to a loud noise or a frightening stimulus. The client admits that they have always been afraid of thunderstorms, which suggests that this is not a new or unusual behavior for them. However, the nurse may want to monitor the client’s anxiety level and provide reassurance and comfort during thunderstorms.
D. Client experiences nightmares.
Client experiences nightmares. This is a finding that requires immediate follow-up because it could indicate post-traumatic stress disorder (PTSD), which is a mental health condition that can develop after witnessing or experiencing a traumatic event. PTSD can cause distressing symptoms such as nightmares, flashbacks, intrusive thoughts, avoidance, negative mood and hyperarousal. PTSD can interfere with the client’s daily functioning and well-being and requires professional treatment.
E. Witnessing their family’s death.
Witnessing their family’s death. This is a finding that requires immediate follow-up because it is the most likely cause of the client’s PTSD symptoms and emotional distress. Witnessing the death of one’s family members is a devastating and traumatic experience that can have lasting effects on the client’s mental health. The client may benefit from grief counseling, trauma-focused therapy, medication or other interventions to help them cope with their loss and trauma.
F. Caregiver reporting client acting differently than usual.
Caregiver reporting client acting differently than usual. This is not a finding that requires immediate follow-up because it is a vague and subjective statement that does not specify how the client is acting differently or what changes have occurred in their behavior. The nurse may want to ask the caregiver for more details and examples of how the client has changed since the traumatic event and assess whether these changes are normal or concerning.
G. Attends school regularly.
Attends school regularly. This is not a finding that requires immediate follow-up because it indicates that the client is maintaining their academic performance and social interactions despite their trauma and grief. Attending school regularly can provide the client with a sense of routine, structure, support and achievement that can help them cope with their situation. However, the nurse may want to check with the client’s teachers and peers to see if they have noticed any changes in the client’s mood, behavior or participation at school.
H. Smoking marijuana to clear their mind.
Smoking marijuana to clear their mind. This is a finding that requires immediate follow-up because it indicates that the client is using an illicit substance to self-medicate their emotional pain. Smoking marijuana can have negative effects on the client’s physical and mental health, such as impairing their memory, cognition, judgment, coordination and motivation. It can also increase the risk of addiction, dependence and withdrawal symptoms. The client may need substance abuse counseling, education, referral or other services to help them quit smoking marijuana and find healthier ways to cope with their feelings.
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Full Explanation
• B: Heart rate 99/min. This is a finding that requires immediate follow-up because it is above the normal range for a 16-year-old client, which is 60 to 100 beats per minute. A high heart rate could indicate anxiety, stress, pain, infection or other conditions that need to be addressed.
• D: Client experiences nightmares. This is a finding that requires immediate follow-up because it could indicate post-traumatic stress disorder (PTSD), which is a mental health condition that can develop after witnessing or experiencing a traumatic event. PTSD can cause distressing symptoms such as nightmares, flashbacks, intrusive thoughts, avoidance, negative mood and hyperarousal. PTSD can interfere with the client’s daily functioning and well-being and requires professional treatment.
• E: Witnessing their family’s death. This is a finding that requires immediate follow-up because it is the most likely cause of the client’s PTSD symptoms and emotional distress. Witnessing the death of one’s family members is a devastating and traumatic experience that can have lasting effects on the client’s mental health. The client may benefit from grief counseling, trauma-focused therapy, medication or other interventions to help them cope with their loss and trauma.
• H: Smoking marijuana to clear their mind. This is a finding that requires immediate follow-up because it indicates that the client is using an illicit substance to self-medicate their emotional pain. Smoking marijuana can have negative effects on the client’s physical and mental health, such as impairing their memory, cognition, judgment, coordination and motivation. It can also increase the risk of addiction, dependence and withdrawal symptoms. The client may need substance abuse counseling, education, referral or other services to help them quit smoking marijuana and find healthier ways to cope with their feelings.
The other findings do not require immediate follow-up for the following reasons:
• A: BP 122/80 mmHg. This is not a finding that requires immediate follow-up because it is within the normal range for a 16-year-old client, which is 110 to 120/70 to 80 mmHg. A normal blood pressure indicates that the client’s cardiovascular system is functioning well and there are no signs of hypertension or hypotension.
• C: Startles easy during thunderstorm. This is not a finding that requires immediate follow-up because it is a normal reaction to a loud noise or a frightening stimulus. The client admits that they have always been afraid of thunderstorms, which suggests that this is not a new or unusual behavior for them. However, the nurse may want to monitor the client’s anxiety level and provide reassurance and comfort during thunderstorms.
• F: Caregiver reporting client acting differently than usual. This is not a finding that requires immediate follow-up because it is a vague and subjective statement that does not specify how the client is acting differently or what changes have occurred in their behavior. The nurse may want to ask the caregiver for more details and examples of how the client has changed since the traumatic event and assess whether these changes are normal or concerning.
• G: Attends school regularly. This is not a finding that requires immediate follow-up because it indicates that the client is maintaining their academic performance and social interactions despite their trauma and grief. Attending school regularly can provide the client with a sense of routine, structure, support and achievement that can help them cope with their situation. However, the nurse may want to check with the client’s teachers and peers to see if they have noticed any changes in the client’s mood, behavior or participation at school.
Similar Questions
A nurse is performing a skin assessment on a client who has dark skin.
Which of the following locations on the client’s body should the nurse observe to assess for cyanosis?
A. Area of trauma.
is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
B. Sacrum.
B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
C. Shoulders.
is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
D. Palms of the hands.
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes. These areas are less affected by melanin, the pigment that gives skin its color.
Full Explanation
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.
Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
A nurse is caring for a client whose partner recently died.
The nurse sits with the client to provide comfort.
Which of the following ethical principles is the nurse demonstrating?
A. Beneficence.
Beneficence. Beneficence is the ethical principle of doing good for the patient and promoting their well-being. The nurse is demonstrating beneficence by sitting with the client to provide comfort and support during a difficult time.
B. Fidelity.
because fidelity is the ethical principle of keeping promises to the patient and being loyal and faithful. The nurse is not making or keeping any promises to the client in this scenario.
C. Autonomy.
because autonomy is the ethical principle of respecting the patient’s right to make their own decisions and choices. The nurse is not interfering with the client’s autonomy in this scenario.
D. Veracity.
wrong because veracity is the ethical principle of telling the truth to the patient and being honest and trustworthy. The nurse is not lying or withholding information from the client in this scenario.
Full Explanation
The correct answer is A. Beneficence. Beneficence is the ethical principle of doing good for the patient and promoting their well-being.
The nurse is demonstrating beneficence by sitting with the client to provide comfort and support during a difficult time.
Choice B is wrong because fidelity is the ethical principle of keeping promises to the patient and being loyal and faithful.
The nurse is not making or keeping any promises to the client in this scenario.
Choice C is wrong because autonomy is the ethical principle of respecting the patient’s right to make their own decisions and choices.
The nurse is not interfering with the client’s autonomy in this scenario.
Choice D is wrong because veracity is the ethical principle of telling the truth to the patient and being honest and trustworthy.
The nurse is not lying or withholding information from the client in this scenario.
A nurse is caring for a client in the medical-surgical unit.
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?
Select all that apply.
A. Review the need for the indwelling urinary catheter daily.
Review the need for the indwelling urinary catheter daily. This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B. Place the drainage bag on the bed when transporting the client.
Place the drainage bag on the bed when transporting the client. This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent backflow of urine and contamination of the catheter.
C. Use soap and water to provide perineal care.
Use soap and water to provide perineal care. This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D. Encourage the client to drink 3000 mL of fluid daily.
Encourage the client to drink 3000 mL of fluid daily. This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E. Change the indwelling urinary catheter tubing every 3 days.
Change the indwelling urinary catheter tubing every 3 days. This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F. Empty the drainage bag when it is half-full.
Empty the drainage bag when it is half-full. This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.
Full Explanation
A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.
C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.