Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?
A. "What would your family do without you?”
Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.
B. "When you get better you will not feel this way.”
Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.
C. "Why would you think a thing like that?”
Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.
D. "Are you thinking of hurting yourself?”
This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Exit 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.
Choice B rationale:
Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.
Choice C rationale:
Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.
Choice D rationale:
This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.
Similar Questions
A nurse in an acute care setting is preparing to administer medications to a client.
Which of the following information should the nurse obtain to identify the client?
A. The client’s date of birth
The client’s date of birth is a critical identifier in healthcare settings. It is unique to the individual and does not change, making it a reliable way to confirm a patient’s identity. This is especially important in acute care settings where accurate patient identification is crucial for safe medication administration. Using the date of birth along with another identifier, such as the patient’s name, aligns with the best practices for patient safety.
B. Client's full medical diagnosis.
While a client’s full medical diagnosis is important information for a nurse to know, it is not used as an identifier for medication administration. The diagnosis helps inform treatment decisions and care planning but does not uniquely identify a patient. Multiple patients could have the same diagnosis, which could lead to medication errors if used as an identifier.
C. Client's telephone number.
A client’s telephone number is not a standard identifier used in healthcare settings for medication administration. Telephone numbers can change and are not unique to an individual. They also do not provide immediate verification of a patient’s identity at the bedside.
D. Room number of the client.
The room number of the client is not a primary identifier for patient identification in medication administration. Room numbers are not unique to individuals and can change if a patient is moved. It is possible for errors to occur if room numbers are used as the sole identifier, as another patient could be in that room at a different time.
Full Explanation
The correct answer is: a. The client’s date of birth.
Choice A reason: The client’s date of birth is a critical identifier in healthcare settings. It is unique to the individual and does not change, making it a reliable way to confirm a patient’s identity. This is especially important in acute care settings where accurate patient identification is crucial for safe medication administration. Using the date of birth along with another identifier, such as the patient’s name, aligns with the best practices for patient safety.
Choice B reason: While a client’s full medical diagnosis is important information for a nurse to know, it is not used as an identifier for medication administration. The diagnosis helps inform treatment decisions and care planning but does not uniquely identify a patient. Multiple patients could have the same diagnosis, which could lead to medication errors if used as an identifier.
Choice C reason: A client’s telephone number is not a standard identifier used in healthcare settings for medication administration. Telephone numbers can change and are not unique to an individual. They also do not provide immediate verification of a patient’s identity at the bedside.
Choice D reason: The room number of the client is not a primary identifier for patient identification in medication administration. Room numbers are not unique to individuals and can change if a patient is moved. It is possible for errors to occur if room numbers are used as the sole identifier, as another patient could be in that room at a different time.
A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations.
Which of the following is the priority action by the nurse?
A. Place a pulse oximeter on the client's finger.
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
B. Establish a patent airway for the client.
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
C. Check the client's pulse rate.
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
D. Administer oxygen to the client.
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
Full Explanation
Choice A rationale:
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
Choice B rationale:
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
Choice C rationale:
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
Choice D rationale:
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
A nurse is collecting data from a client who is 2 days postpartum.
The client tells the nurse she cannot afford to pay for baby formula.
The nurse should refer the client to which of the following members of the interprofessional team?
A. Nutritionist.
Referring the client to a nutritionist is not the most appropriate action in this situation. While nutritionists can provide valuable information on infant feeding, the client's primary concern is the inability to afford baby formula. A case manager is better suited to address the client's financial and social needs.
B. Primary care provider.
Referring the client to the primary care provider is not the most appropriate action in this situation. The primary care provider may not have the resources or expertise to address the client's financial and social concerns.
C. Pediatric nurse practitioner.
Referring the client to a pediatric nurse practitioner is not the most appropriate action in this situation. While pediatric nurse practitioners can provide healthcare for infants, they may not have the resources to address the client's financial constraints.
D. Case manager.
Referring the client to a case manager is the most appropriate action in this scenario. A case manager can assess the client's financial situation and connect them with appropriate resources, such as government assistance programs or local charities, to help cover the cost of baby formula. Case managers specialize in coordinating care and addressing social determinants of health.
Full Explanation
Choice A rationale:
Referring the client to a nutritionist is not the most appropriate action in this situation. While nutritionists can provide valuable information on infant feeding, the client's primary concern is the inability to afford baby formula. A case manager is better suited to address the client's financial and social needs.
Choice B rationale:
Referring the client to the primary care provider is not the most appropriate action in this situation. The primary care provider may not have the resources or expertise to address the client's financial and social concerns.
Choice C rationale:
Referring the client to a pediatric nurse practitioner is not the most appropriate action in this situation. While pediatric nurse practitioners can provide healthcare for infants, they may not have the resources to address the client's financial constraints.
Choice D rationale:
Referring the client to a case manager is the most appropriate action in this scenario. A case manager can assess the client's financial situation and connect them with appropriate resources, such as government assistance programs or local charities, to help cover the cost of baby formula. Case managers specialize in coordinating care and addressing social determinants of health.