Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is experiencing suicidal thoughts.
Which of the following actions should the nurse take?.
A. Place the client on 12-hour observation.
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
B. Remove harmful objects from the client's room.
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
C. Encourage visitors for the client at any time.
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
D. Encourage visitors to bring items to the client.
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Custom Nurs 120 Psychiatric Nursing Fa23 Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale:
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
Choice B rationale:
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
Choice C rationale:
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
Choice D rationale:
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.
Similar Questions
A nurse is caring for a client who has been prescribed clozapine.
Which of the following topics should the nurse prepare to discuss with the client?.
A. The importance of medication adherence after the resolution of acute psychosis when taking an antipsychotic.
Adherence to medication, especially after the resolution of acute psychosis, is crucial when taking an antipsychotic like clozapine. This is because discontinuation can lead to a relapse of symptoms.
B. The importance of limiting fluid intake when taking an antipsychotic.
There’s no specific need to limit fluid intake when taking an antipsychotic.
C. The importance of routine red blood cell count laboratory work when taking an antipsychotic.
While routine blood cell count laboratory work is important, it’s not specific to red blood cells but rather to monitor for agranulocytosis, a potential side effect of clozapine.
D. The importance of avoiding foods that contain tyramine when taking an antipsychotic.
Avoiding foods that contain tyramine is typically associated with monoamine oxidase inhibitors, not antipsychotics like clozapine.
Full Explanation
Choice A rationale:
Adherence to medication, especially after the resolution of acute psychosis, is crucial when taking an antipsychotic like clozapine. This is because discontinuation can lead to a relapse of symptoms.
Choice B rationale:
There’s no specific need to limit fluid intake when taking an antipsychotic.
Choice C rationale:
While routine blood cell count laboratory work is important, it’s not specific to red blood cells but rather to monitor for agranulocytosis, a potential side effect of clozapine.
Choice D rationale:
Avoiding foods that contain tyramine is typically associated with monoamine oxidase inhibitors, not antipsychotics like clozapine.
A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation.
Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?
A. "I'm going to continue to not drink alcohol when I get home.”.
Continuing to abstain from alcohol is a positive step towards maintaining mental health, not a sign of suicidal ideation.
B. "Walking around the hospital grounds has been helping me.”.
Finding therapeutic activities like walking around the hospital grounds is a positive coping mechanism, not a sign of suicidal ideation.
C. "I'm looking forward to seeing my grandchildren when I get out of here.”.
Looking forward to future events like seeing grandchildren is a positive sign and not indicative of suicidal ideation.
D. "I'm going to give my sister my pottery collection when I get home.”. .
Giving away possessions, like a pottery collection, can be a sign of suicidal ideation as it may indicate the client is putting their affairs in order.
Full Explanation
Choice A rationale:
Continuing to abstain from alcohol is a positive step towards maintaining mental health, not a sign of suicidal ideation.
Choice B rationale:
Finding therapeutic activities like walking around the hospital grounds is a positive coping mechanism, not a sign of suicidal ideation.
Choice C rationale:
Looking forward to future events like seeing grandchildren is a positive sign and not indicative of suicidal ideation.
Choice D rationale:
Giving away possessions, like a pottery collection, can be a sign of suicidal ideation as it may indicate the client is putting their affairs in order.
A nurse is teaching a client who has bipolar disorder about lithium.
Which of the following statements should the nurse include in the teaching?.
A. "Take the medication on an empty stomach.”.
Taking lithium on an empty stomach is not necessary. Lithium can be taken with or without food.
B. "You might produce extra saliva while taking this medication.”.
Excessive salivation is not a common side effect of lithium.
C. "Notify your provider if you experience vomiting or diarrhea.”.
Vomiting or diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium. Therefore, it’s important to notify your provider if you experience these symptoms.
D. "Decrease your fluid intake to 1 liter per day.”.
Decreasing fluid intake can lead to dehydration and increase the risk of lithium toxicity. It’s recommended to maintain a normal fluid intake while taking lithium.
Full Explanation
Choice A rationale:
Taking lithium on an empty stomach is not necessary. Lithium can be taken with or without food.
Choice B rationale:
Excessive salivation is not a common side effect of lithium.
Choice C rationale:
Vomiting or diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium. Therefore, it’s important to notify your provider if you experience these symptoms.
Choice D rationale:
Decreasing fluid intake can lead to dehydration and increase the risk of lithium toxicity. It’s recommended to maintain a normal fluid intake while taking lithium.