Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.
A. Lower the window shade in the client's room.
A rationale: Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.
B. Obtain a PRN prescription for a vest restraint.
B rationale: Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.
C. Place the client in a room close to the nurses' station.
C rationale: Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.
D. Request a consult with recreational therapy.
D rationale: While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.
Choice B rationale:
Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.
Choice C rationale:
Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.
Choice D rationale:
While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.
Similar Questions
A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder.
Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.
Use a leading zero if it applies.
Do not use a trailing zero.).
Full Explanation
The correct answer is 2.5 mL. Calculation: Identify the desired dose: 50 mg Identify the available dose: 20 mg/mL Apply the formula: Desired ÷ Available = Volume to administer Calculation: 50 mg ÷ 20 mg/mL = 2.5 mL
A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy.
The nurse should notify the provider for which of the following findings?.
A. Cardiac arrhythmia
A rationale: Cardiac arrhythmia is a contraindication for electroconvulsive therapy (ECT) because ECT can cause changes in heart rate and blood pressure, which could be dangerous for someone with an existing heart condition.
B. Crohn's disease.
B rationale: Crohn’s disease is not a contraindication for ECT. It is a chronic inflammatory bowel disease, and while it can cause significant health problems, it does not directly affect the safety or efficacy of ECT.
C. Renal colic.
C rationale: Renal colic, a type of pain that can occur when a kidney stone is present, is not a contraindication for ECT. It is unrelated to the brain and nervous system and does not affect the safety or efficacy of ECT.
D. Asthma.
D rationale: Asthma is not a contraindication for ECT. While severe asthma should be well-controlled before any procedure that involves anesthesia, it is not a direct contraindication for ECT.
Full Explanation
Choice A rationale:
Cardiac arrhythmia is a contraindication for electroconvulsive therapy (ECT) because ECT can cause changes in heart rate and blood pressure, which could be dangerous for someone with an existing heart condition.
Choice B rationale:
Crohn’s disease is not a contraindication for ECT. It is a chronic inflammatory bowel disease, and while it can cause significant health problems, it does not directly affect the safety or efficacy of ECT.
Choice C rationale:
Renal colic, a type of pain that can occur when a kidney stone is present, is not a contraindication for ECT. It is unrelated to the brain and nervous system and does not affect the safety or efficacy of ECT.
Choice D rationale:
Asthma is not a contraindication for ECT. While severe asthma should be well-controlled before any procedure that involves anesthesia, it is not a direct contraindication for ECT.
A nurse is contributing to the plan of care for a client who has a new prescription for lithium.
Which of the following interventions should the nurse recommend?.
A. Administer the medication with meals.
A rationale: Administering lithium with meals can help reduce gastrointestinal upset, a common side effect of the medication.
B. Monitor the client for hypoglycemia.
B rationale: Lithium does not typically cause hypoglycemia. It primarily affects the nervous system and kidneys.
C. Decrease the client's dietary potassium.
C rationale: There’s no need to decrease dietary potassium. Lithium can affect sodium levels, but not potassium.
D. Increase the client's daily caloric intake.
D rationale: Increasing daily caloric intake is not necessary when taking lithium. The medication does not affect metabolism or caloric needs.
Full Explanation
Choice A rationale:
Administering lithium with meals can help reduce gastrointestinal upset, a common side effect of the medication.
Choice B rationale:
Lithium does not typically cause hypoglycemia. It primarily affects the nervous system and kidneys.
Choice C rationale:
There’s no need to decrease dietary potassium. Lithium can affect sodium levels, but not potassium.
Choice D rationale:
Increasing daily caloric intake is not necessary when taking lithium. The medication does not affect metabolism or caloric needs.