Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has experienced a stroke and is moving in with their adult child.
Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
A. Implement firm but flexible boundaries in their relationship.
. Implement firm but flexible boundaries in their relationship. This is because boundaries can help the client and family to respect each other’s roles, needs and preferences, and to avoid role confusion, resentment or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
B. Minimize open discussion regarding the changes to avoid embarrassment.
minimizing open discussion regarding the changes can lead to misunderstanding, frustration or isolation. The client and family should communicate openly and honestly about their feelings, expectations and challenges, and seek support when needed.
C. Encourage authoritative communication from the adult child.
because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
D. Decrease socialization with extended relatives until roles are identified.
decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
E. undefined
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice A. Implement firm but flexible boundaries in their relationship.
This is because boundaries can help the client and family to respect each other’s roles, needs and preferences, and to avoid role confusion, resentment or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.
Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration or isolation. The client and family should communicate openly and honestly about their feelings, expectations and challenges, and seek support when needed.
Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.
Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.
Similar Questions
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care.
Which of the following instructions should the nurse include in the teaching?
A. Soak feet twice daily.
because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
B. Wear clean cotton socks every day.
Wear clean cotton socks every day. This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
C. Round the edges of toenails when trimming.
rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
D. Use moisturizing lotion between the toes.
is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
E. undefined
Full Explanation
The correct answer is choice B. Wear clean cotton socks every day.
This is because cotton socks can help keep the feet dry and prevent infections. Wearing clean socks every day can also prevent blisters and injuries from friction.
Choice A is wrong because soaking feet twice daily can make the skin too soft and prone to injury. It can also wash away natural oils that protect the skin.
Choice C is wrong because rounding the edges of toenails when trimming can cause ingrown nails, which can lead to infection and pain. Toenails should be trimmed straight across and filed smooth.
Choice D is wrong because using moisturizing lotion between the toes can create a moist environment that promotes fungal growth. Moisturizing lotion should be applied to the rest of the feet, but not between the toes.
Some other foot care guidelines for people with diabetes are:
- Inspect your feet daily and look for signs of injury, such as scrapes, cuts, blisters, etc.
- Wash your feet every day in warm water with mild soap.
Hot water and harsh soaps can damage your skin. Check the water temperature with your fingers or elbow before putting your feet in.
- Don’t walk barefoot.
Protect your feet from heat and cold. Wear appropriate fitting shoes to avoid injury and blisters.
- See a doctor to remove corns or calluses (don’t do it yourself). Don’t use chemical wart removers, razor blades, corn plasters, or liquid corn or callus removers.
- Don’t sit with your legs crossed or stand in one position for long periods of time.
- See your doctor regularly for foot exams and report any problems or changes in your feet.
References:
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion.
For which of the following therapeutic effects should the nurse monitor the client
A. Deep tendon reflexes 2+.
Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy, to reduce the risk of seizures or eclampsia. It can also prolong pregnancy for up to two days, allowing drugs that speed up the baby’s lung development to be administered.
B. 1+ proteinuria via urine dipstick.
wrong because 1+ proteinuria via urine dipstick is not a therapeutic effect of magnesium sulfate, but a sign of preeclampsia. Proteinuria indicates that the kidneys are not working properly and are leaking protein into the urine. Magnesium sulfate does not improve the outcomes for the baby and can cause side effects such as respiratory depression for the mother.
C. Pulse rate 100/min.
because pulse rate 100/min is not a therapeutic effect of magnesium sulfate, but a possible side effect. Magnesium sulfate can cause vasodilation, which lowers blood pressure and increases heart rate. A normal pulse rate for an adult is between 60 and 100 beats per minute. A pulse rate higher than 100 beats per minute may indicate tachycardia, which can be caused by various factors such as anxiety, dehydration, fever, infection, or medication.
D. Urine output 20 mL/hr.
because urine output 20 mL/hr is not a therapeutic effect of magnesium sulfate, but a sign of kidney failure. A normal urine output for an adult is between 800 and 2000 mL per day, or about 30 to 80 mL per hour. A urine output lower than 30 mL per hour may indicate oliguria, which can be caused by various factors such as dehydration, blood loss, shock, or kidney damage. Magnesium sulfate can cause renal toxicity if given in high doses or for prolonged periods.
E. undefined
None
Full Explanation
The correct answer is choice A. Deep tendon reflexes 2+. This indicates that the client is receiving the therapeutic effect of magnesium sulfate, which is to prevent seizures by reducing neuromuscular excitability.
Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy, to reduce the risk of seizures or eclampsia. It can also prolong pregnancy for up to two days, allowing drugs that speed up the baby’s lung development to be administered.
Choice B is wrong because 1+ proteinuria via urine dipstick is not a therapeutic effect of magnesium sulfate, but a sign of preeclampsia.
Proteinuria indicates that the kidneys are not working properly and are leaking protein into the urine. Magnesium sulfate does not improve the outcomes for the baby and can cause side effects such as respiratory depression for the mother.
Choice C is wrong because pulse rate 100/min is not a therapeutic effect of magnesium sulfate, but a possible side effect.
Magnesium sulfate can cause vasodilation, which lowers blood pressure and increases heart rate. A normal pulse rate for an adult is between 60 and 100 beats per minute. A pulse rate higher than 100 beats per minute may indicate tachycardia, which can be caused by various factors such as anxiety, dehydration, fever, infection, or medication.
Choice D is wrong because urine output 20 mL/hr is not a therapeutic effect of magnesium sulfate, but a sign of kidney failure. A normal urine output for an adult is between 800 and 2000 mL per day, or about 30 to 80 mL per hour. A urine output lower than 30 mL per hour may indicate oliguria, which can be caused by various factors such as dehydration, blood loss, shock, or kidney damage. Magnesium sulfate can cause renal toxicity if given in high doses or for prolonged periods.
A nurse has just received change-of-shift report for four clients.
Which of the following clients should the nurse assess first?
A. A client who is scheduled for a procedure in 1 hr.
wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later. The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.
B. A client who received a pain medication 30 min ago for postoperative pain.
wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.
C. A client who was just given a glass of orange juice for a low blood glucose level.
A client who was just given a glass of orange juice for a low blood glucose level. This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly. The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.
D. A client who has 100 mL of fluid remaining in his IV bag.
wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.
E. undefined
Full Explanation
The correct answer is choice C. A client who was just given a glass of orange juice for a low blood glucose level.
This client should be assessed first because they are at risk of hypoglycemia, which is a medical emergency that can cause seizures, coma, or death if not treated promptly.
The nurse should check the client’s blood glucose level again and provide additional carbohydrates or glucose if needed.
Choice A is wrong because a client who is scheduled for a procedure in 1 hr is not in immediate danger and can be assessed later.
The nurse should verify the client’s consent, allergies, and vital signs before the procedure, but this is not a priority over a client with low blood glucose.
Choice B is wrong because a client who received a pain medication 30 min ago for postoperative pain is likely to have improved pain relief and does not need immediate assessment.
The nurse should monitor the client’s pain level, vital signs, and respiratory status periodically, but this is not a priority over a client with low blood glucose.
Choice D is wrong because a client who has 100 mL of fluid remaining in his IV bag is not in immediate danger and can be assessed later.
The nurse should change the IV bag when it is empty or nearly empty, but this is not a priority over a client with low blood glucose.
Normal blood glucose levels are between 70 to 100 mg/dL (3.9 to 5.5 mmol/L) when fasting, and less than 140 mg/dL (7.8 mmol/L) two hours after eating. A blood glucose level below 70 mg/dL (3.9 mmol/L) is considered hypoglycemia and requires immediate treatment. Orange juice is a source of simple carbohydrates that can raise blood glucose quickly, but it may not be enough to prevent hypoglycemia in some cases.