Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?
A. "When you get better you will not feel this way."
B. "Are you thinking of hurting yourself?"
The nurse should assess the client's risk for suicide by asking directly about suicidal thoughts or plans. This is a priority intervention that can help prevent harm to the client and provide appropriate referrals for further evaluation and treatment.
C. "What would your family do without you?"
D. "Why would you think a thing like that?"
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is B. The nurse should assess the client's risk for suicide by asking directly about suicidal thoughts or plans. This is a priority intervention that can help prevent harm to the client and provide appropriate referrals for further evaluation and treatment.
Similar Questions
A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?
A. Instruct the client to exhale while inserting the rectal tube.
The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are incorrect because they can cause injury or discomfort to the client.
B. Insert the tip of the rectal tube 15 cm (6 in).
C. Administer the enema using cool tap water.
D. Administer a second enema if the first has poor results.
Full Explanation
The correct answer is A. The nurse should instruct the client to exhale while inserting the rectal tube to relax the anal sphincter and facilitate insertion. The other options are
incorrect because they can cause injury or discomfort to the client.
A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference?
A. A client who has a spinal cord injury
A client who has a spinal cord injury requires an interprofessional approach to care that involves multiple disciplines such as physical therapy, occupational therapy, social work, and rehabilitation nursing. The other clients have less complex needs that can be managed by one or two disciplines.
B. A client who has acute appendicitis
C. A client who has a urinary tract infection
D. A client who has a torn rotator cuff
Full Explanation
The correct answer is A. A client who has a spinal cord injury requires an interprofessional approach to care that involves multiple disciplines such as physical therapy, occupational therapy, social work, and rehabilitation nursing. The other clients have less complex needs that can be managed by one or two disciplines.
A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?
A. The AP inserts the probe with a straightforward motion.
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
B. The AP positions the client facing her.
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
C. The AP pulls the pinna up and back
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
D. The AP points the probe posteriorly.
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.
Full Explanation
The correct answer is choice C. The AP pulls the pinna up and back.
Choice A rationale:
Inserting the probe with a straightforward motion is not sufficient to ensure an accurate reading. Proper positioning of the ear canal is necessary to get an accurate tympanic temperature.
Choice B rationale:
Positioning the client facing the AP is not relevant to the accuracy of the tympanic temperature measurement. The focus should be on the correct technique for inserting the probe.
Choice C rationale:
Pulling the pinna up and back is the correct technique for adults and children over 3 years old. This action straightens the ear canal, allowing for an accurate temperature reading.
Choice D rationale:
Pointing the probe posteriorly is not a standard guideline for taking a tympanic temperature. The probe should be aimed towards the eardrum for an accurate measurement.