Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has been diagnosed with schizophrenia.
The client has been wearing the same clothes for the past week and appears unkept and unbathed.
Which of the following statements should the nurse make to the client?
A. "I'm going to ignore your lack of self-care because it is an aspect of the disorder.”.
A rationale: Ignoring the client’s lack of self-care is not therapeutic. It’s important to address hygiene issues with clients who have schizophrenia.
B. "This is it! You are getting a bath! There are three of us here to bathe you!".
B rationale: This approach is confrontational and does not respect the client’s autonomy or dignity.
C. "It is now time for you to bathe.
C rationale: This is the best choice because it respects the client’s autonomy and provides them with a choice, which can help motivate them to participate in self-care activities.
D. "Do you really think it is ok not to bathe? What is going on with you?".
D rationale: This statement is judgmental and confrontational, which is not therapeutic.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NUR 316 Fall 2023 1MHE Module 4 - 1st 5 units Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Ignoring the client’s lack of self-care is not therapeutic. It’s important to address hygiene issues with clients who have schizophrenia.
Choice B rationale:
This approach is confrontational and does not respect the client’s autonomy or dignity.
Choice C rationale:
This is the best choice because it respects the client’s autonomy and provides them with a choice, which can help motivate them to participate in self-care activities.
Choice D rationale:
This statement is judgmental and confrontational, which is not therapeutic.
Similar Questions
A nurse is caring for a client who is experiencing excessive anxiety and worry in response to a variety of circumstances and is unable to control their sense of worry.
The nurse should identify that these manifestations indicate which of the following?.
A. "I can understand your concerns.
A rationale: Separation anxiety disorder is characterized by excessive fear or anxiety about separation from those to whom the individual is attached.
B. Agoraphobia.
B rationale: Agoraphobia involves marked fear or anxiety about two or more of the following: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside of the home alone.
C. Panic disorder.
C rationale: Panic disorder is characterized by recurrent unexpected panic attacks, which are abrupt surges of intense fear or discomfort that reach a peak within minutes.
D. Generalized anxiety disorder.
D rationale: Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of events or activities. The individual finds it difficult to control the worry.
Full Explanation
Choice A rationale:
Separation anxiety disorder is characterized by excessive fear or anxiety about separation from those to whom the individual is attached.
Choice B rationale:
Agoraphobia involves marked fear or anxiety about two or more of the following: using public transportation, being in open spaces, being in enclosed places, standing in line or being in a crowd, or being outside of the home alone.
Choice C rationale:
Panic disorder is characterized by recurrent unexpected panic attacks, which are abrupt surges of intense fear or discomfort that reach a peak within minutes.
Choice D rationale:
Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of events or activities. The individual finds it difficult to control the worry.
A nurse is responding to a parent of an adolescent who was recently diagnosed with posttraumatic stress disorder following a sexual assault.
The parent states, "My child ignores curfew, is hanging out with a rough crowd, and has been experimenting with drugs.
Why would they be doing this?" Which of the following responses should the nurse make?.
A. Pill rolling movements and drooling.
A rationale: While it’s important to address the parent’s concerns, this response does not provide the parent with information about why their child might be exhibiting these behaviors.
B. "It is very frustrating when children misbehave.
B rationale: This response does not address the parent’s question about why their child is exhibiting these behaviors.
C. "This must be a difficult time for you.
C rationale: This is the best choice because it provides the parent with information about why their child might be exhibiting these behaviors.
D. "This is normal behavior for an adolescent.
D rationale: This response minimizes the parent’s concerns and does not provide them with information about why their child might be exhibiting these behaviors.
Full Explanation
Choice A rationale:
While it’s important to address the parent’s concerns, this response does not provide the parent with information about why their child might be exhibiting these behaviors.
Choice B rationale:
This response does not address the parent’s question about why their child is exhibiting these behaviors.
Choice C rationale:
This is the best choice because it provides the parent with information about why their child might be exhibiting these behaviors.
Choice D rationale:
This response minimizes the parent’s concerns and does not provide them with information about why their child might be exhibiting these behaviors.
A nurse is caring for a client who ingested a selective serotonin reuptake inhibitor and St. John's Wort.
Which of the following findings should the nurse identify as being consistent with serotonin syndrome?.
A. Blood pressure
A rationale: Pill rolling movements and drooling are symptoms of Parkinson’s disease, not serotonin syndrome.
B. Suicidal ideations.
B rationale: Suicidal ideations are a serious mental health concern, but they are not a symptom of serotonin syndrome.
C. Tinnitus and jerking movements.
C rationale: Tinnitus and jerking movements can be symptoms of various conditions, but they are not typically associated with serotonin syndrome.
D. Dilated pupils and loss of muscle coordination.
D rationale: Dilated pupils and loss of muscle coordination are symptoms of serotonin syndrome, which can occur due to an excess of serotonin, often as a result of a combination of medications.
Full Explanation
Choice A rationale:
Pill rolling movements and drooling are symptoms of Parkinson’s disease, not serotonin syndrome.
Choice B rationale:
Suicidal ideations are a serious mental health concern, but they are not a symptom of serotonin syndrome.
Choice C rationale:
Tinnitus and jerking movements can be symptoms of various conditions, but they are not typically associated with serotonin syndrome.
Choice D rationale:
Dilated pupils and loss of muscle coordination are symptoms of serotonin syndrome, which can occur due to an excess of serotonin, often as a result of a combination of medications.