Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
A. Determine if the client is experiencing suicidal ideation.
Assessing for the client's immediate safety is the first priority in crisis intervention.
B. Identify the client's social support.
Identifying social support is important but not the primary action in this situation.
C. Instruct the client about coping skills.
Instructing the client about coping skills is important, but immediate safety takes precedence.
D. Explore the client's perception of the event.
Exploring the client's perception of the event is valuable, but assessing for suicidality is more urgent.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Assessing for the client's immediate safety is the first priority in crisis intervention.
Choice B rationale:
Identifying social support is important but not the primary action in this situation.
Choice C rationale:
Instructing the client about coping skills is important, but immediate safety takes precedence.
Choice D rationale:
Exploring the client's perception of the event is valuable, but assessing for suicidality is more urgent.
Similar Questions
A nurse is teaching a client who experiences anaphylaxis from bee stings about an epinephrine auto-injector. Which of the following client statements indicates an understanding of the teaching?
A. "I should shake the device if the medication appears brown."
Shaking the auto-injector is not recommended as it could disrupt the medication's effectiveness. Epinephrine auto-injectors contain two separate components that need to be mixed upon injection.
B. "I should not massage the injection area."
Massaging the injection site after using the auto-injector can actually help disperse the medication and promote absorption and reduce pain and swelling.
C. "I will inject the medication in the top of my thigh."
Injecting the medication into the top of the thigh is the correct administration site and technique for an epinephrine auto-injector. It's a large muscle area that allows for rapid absorption.
D. "I will refrigerate the injection device when I am at home."
Epinephrine auto-injectors should not be refrigerated, as extreme temperatures can affect their functionality. The client should store the device at room temperature away from light and heat sources.
Full Explanation
Choice A rationale:
Shaking the auto-injector is not recommended as it could disrupt the medication's effectiveness. Epinephrine auto-injectors contain two separate components that need to be mixed upon injection.
Choice B rationale:
Massaging the injection site after using the auto-injector can actually help disperse the medication and promote absorption and reduce pain and swelling.
Choice C rationale:
Injecting the medication into the top of the thigh is the correct administration site and technique for an epinephrine auto-injector. It's a large muscle area that allows for rapid absorption.
Choice D rationale:
Epinephrine auto-injectors should not be refrigerated, as extreme temperatures can affect their functionality. The client should store the device at room temperature away from light and heat sources.
A nurse is teaching a young adult female client who has sickle cell anemia and a new prescription for hydroxyurea. Which of the following information should the nurse include in the teaching?
A. "You will need to have your blood drawn every 2 weeks."
B. "You will self-administer one dose intramuscularly each day."
C. "This medication is safe to take if you become pregnant.
D. "You should limit your daily fluid intake to 1 and a half liters."
A nurse is providing teaching to a client who has a new prescription for a transdermal contraceptive patch. Which of the following instructions should the nurse include?
A. "Expect heavier menstrual bleeding while using the patch."
While some women might experience lighter periods while using hormonal contraceptives, heavier menstrual bleeding is not an expected outcome of using the patch.
B. "Place the patch on the upper thigh."
The patch should be applied to areas like the upper outer arm, abdomen, buttock, or upper torso. The upper thigh is not recommended as an application site.
C. "Apply the first patch within 24 hours of starting your menstrual cycle."
The first patch is typically applied on the first day of the menstrual cycle, but it can also be applied within 24 hours of starting the cycle. This timing helps with immediate contraceptive coverage.
D. "Apply a new patch at the same time each day."
Applying a new patch at the same time each day helps maintain a consistent hormonal level, which is important for contraceptive effectiveness.
Full Explanation
A: Expecting heavier menstrual bleeding while using the patch is not a typical instruction given to clients. The patch may actually result in lighter, more regular bleeding.
B: The patch should not be placed on the upper thigh. According to the guidelines, the patch should be applied to clean, dry skin on the belly, buttocks, or back, and can also be placed on the outer part of the upper arm.
C: Applying the first patch within 24 hours of starting the menstrual cycle is correct. This ensures that the patch begins to work in sync with the client's natural cycle, providing immediate contraceptive protection.
D: A new patch should not be applied at the same time each day. Instead, it should be changed once a week on the same day, known as the "patch change day" to maintain consistent contraceptive coverage.