Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
A. Explain the client that the behavior was unacceptable.
While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.
B. Explore the truth of the client's statements.
This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.
C. Set behavioral limits for the client.
Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.
D. Establish a client relationship
Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Mental Health Proctored Exam. Take the full exam now
Full Explanation
A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.
B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.
C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.
D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.
Similar Questions
A nurse is caring for a young adult client following the sudden death of his wife. The client feels paralyzed in his ability to cope with work and family responsibilities. Which of the following types of crisis is the client experiencing?
A. Maturational
This type of crisis arises from normal life transitions, such as entering a new stage of development (adolescence, midlife crisis, etc.). It involves a struggle to adapt to new roles and responsibilities. The client's situation does involve a life transition due to the death of his wife, but the sudden nature of the event and the resulting distress suggest a situational crisis.
B. Adventitious
Adventitious crises are caused by extraordinary events that are external to the individual's usual experience, such as natural disasters, accidents, or crimes. While the sudden death of the client's wife is an unexpected and tragic event, it's not an adventitious crisis because it involves personal loss rather than a large-scale or external event.
C. Developmental
Developmental crises are associated with specific stages of life and the challenges and changes that come with them. This crisis doesn't seem to fit the developmental category as it is more tied to the specific event of the wife's sudden death.
D. Situational
A situational crisis is a type of crisis that arises from a specific event or situation that disrupts an individual's normal functioning and coping abilities. In this case, the sudden death of the client's wife is the triggering event that has led to his feeling paralyzed and overwhelmed in his ability to cope with work and family responsibilities. Situational crises are often unexpected and can lead to a temporary state of disorganization and distress.
Full Explanation
A) Maturational crisis:
This type of crisis arises from normal life transitions, such as entering a new stage of development (adolescence, midlife crisis, etc.). It involves a struggle to adapt to new roles and responsibilities. The client's situation does involve a life transition due to the death of his wife, but the sudden nature of the event and the resulting distress suggest a situational crisis.
B) Adventitious crisis:
Adventitious crises are caused by extraordinary events that are external to the individual's usual experience, such as natural disasters, accidents, or crimes. While the sudden death of the client's wife is an unexpected and tragic event, it's not an adventitious crisis because it involves personal loss rather than a large-scale or external event.
C) Developmental crisis:
Developmental crises are associated with specific stages of life and the challenges and changes that come with them. This crisis doesn't seem to fit the developmental category as it is more tied to the specific event of the wife's sudden death.
D) Situational crisis
Explanation:
A situational crisis is a type of crisis that arises from a specific event or situation that disrupts an individual's normal functioning and coping abilities. In this case, the sudden death of the client's wife is the triggering event that has led to his feeling paralyzed and overwhelmed in his ability to cope with work and family responsibilities. Situational crises are often unexpected and can lead to a temporary state of disorganization and distress.
A nurse at a walk in mental health clinic is assessing a client experiencing severe anxiety. The nurse should recognize the client might exhibit which of the following manifestations?
A. Attention-seeking conduct
In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.
B. Wild fidgeting
Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.
C. Threatening behavior
While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.
D. Mild difficulty problem solving
Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.
Full Explanation
A. In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.
B. Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.
C.While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.
D. Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.
A nurse is caring for a client who reports an upset stomach after taking chlorpromazine. Which of the following responses should the nurse make?
A. “Taking the medication on an empty stomach will decrease your stomach upset."
This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.
B. "Lie down for 30 minutes after each dose to help prevent stomach upset."
This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.
C. "Talk to your provider about decreasing your dose of medication,"
While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.
D. "Drink a glass of milk with each dose of your medication."
Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.
Full Explanation
A. “Taking the medication on an empty stomach will decrease your stomach upset." This is incorrect because taking chlorpromazine on an empty stomach can actually increase the risk of gastrointestinal irritation and upset. It’s generally recommended to take medications that can irritate the stomach lining with food or milk to help buffer the stomach.
B. “Lie down for 30 minutes after each dose to help prevent stomach upset.” This is not a recommended practice for preventing stomach upset. In fact, lying down immediately after taking medication can increase the risk of esophageal irritation and reflux, especially with certain medications.
C. “Talk to your provider about decreasing your dose of medication.” While discussing medication concerns with a healthcare provider is always a good idea, this response does not directly address the immediate issue of stomach upset. The provider might adjust the dose if necessary, but the primary recommendation for reducing stomach upset would be to take the medication with milk.
D. “Drink a glass of milk with each dose of your medication.” Drinking milk with chlorpromazine can help reduce stomach upset by buffering the stomach lining and reducing irritation. This is a common recommendation for medications that can cause gastrointestinal discomfort.