Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is Caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
A. Disclose some personal information to the client to demonstrate approachability.
Sharing personal information can blur the professional boundaries and might not be effective in reducing the client's suspicion. It's important to maintain a professional demeanor while building trust.
B. Approach the client frequently throughout the day for brief interactions.
While it's important to establish a presence and provide support, approaching the client too frequently might increase their discomfort and reinforce their suspicion. It's better to allow the client some personal space while ensuring they know you are available when needed.
C. Adopt a neutral attitude when providing care.
When dealing with a client who is extremely suspicious, it's important for the nurse to approach the situation with a neutral attitude. A neutral attitude helps to build trust and minimize any potential triggers for the client's suspicion. This approach creates a non-threatening environment where the client may feel more comfortable and gradually begin to open up.
D. Wait for the client to initiate interaction.
While giving the client space is important, waiting for them to initiate interaction might prolong the development of a therapeutic relationship. Clients who are extremely suspicious might have difficulty initiating interactions due to their concerns.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Mental Health Proctored Exam. Take the full exam now
Full Explanation
Sharing personal information can blur the professional boundaries and might not be effective in reducing the client's suspicion. It's important to maintain a professional demeanor while building trust.
B) Approach the client frequently throughout the day for brief interactions:
While it's important to establish a presence and provide support, approaching the client too frequently might increase their discomfort and reinforce their suspicion. It's better to allow the client some personal space while ensuring they know you are available when needed.
C) Adopt a neutral attitude when providing care.
Explanation:
When dealing with a client who is extremely suspicious, it's important for the nurse to approach the situation with a neutral attitude. A neutral attitude helps to build trust and minimize any potential triggers for the client's suspicion. This approach creates a non-threatening environment where the client may feel more comfortable and gradually begin to open up.
D) Wait for the client to initiate interaction:
While giving the client space is important, waiting for them to initiate interaction might prolong the development of a therapeutic relationship. Clients who are extremely suspicious might have difficulty initiating interactions due to their concerns.
Similar Questions
A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings are risk factors of depression? (Select all that apply.)
A. Low self-esteem
Low self-esteem is a risk factor for depression because negative self-perception and feelings of worthlessness can contribute to the development of depressive symptoms.
B. Irritability
Irritability is associated with depression, especially in adolescents. It can manifest as a mood symptom and is often seen alongside other depressive features.
C. Chronic pain
Chronic pain can be both a symptom and a risk factor for depression. Persistent pain can lead to changes in mood, behavior, and physical function, contributing to the development of depressive symptoms.
D. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression and can also be a risk factor. Sleep disturbances are often seen in individuals with depression, and they can contribute to the severity of the condition.
E. Euphoria
Euphoria is not a risk factor for depression. In fact, it is more commonly associated with conditions like bipolar disorder, where individuals experience periods of elevated mood (mania or hypomania) alternating with periods of depression.
Full Explanation
A. Low self-esteem is a risk factor for depression because negative self-perception and feelings of worthlessness can contribute to the development of depressive symptoms.
B. Irritability is associated with depression, especially in adolescents. It can manifest as a mood symptom and is often seen alongside other depressive features.
C. Chronic pain can be both a symptom and a risk factor for depression. Persistent pain can lead to changes in mood, behavior, and physical function, contributing to the development of depressive symptoms.
D. Insomnia, or difficulty sleeping, is a common symptom of depression and can also be a risk factor. Sleep disturbances are often seen in individuals with depression, and they can contribute to the severity of the condition.
E. Euphoria is not a risk factor for depression. In fact, it is more commonly associated with conditions like bipolar disorder, where individuals experience periods of elevated mood (mania or hypomania) alternating with periods of depression.
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. He will monitor your lithium levels closely while you are taking this medication."
Lithium is a commonly used medication for treating bipolar disorder, and therapeutic drug monitoring is crucial to ensure its effectiveness and prevent potential toxicity. Monitoring the client's lithium levels in the blood is important because lithium has a narrow therapeutic range, meaning that levels that are too low might not provide the desired therapeutic effect, while levels that are too high can lead to toxicity.
B. This medication is addictive, so you will need to discontinue it in six months."
"This medication is addictive, so you will need to discontinue it in six months."Lithium is not considered addictive. It's important to provide accurate information about the nature of the medication to avoid unnecessary concerns.
C. "Weight gain should be reported to your provider as an indication of lithium toxicity."
"Weight gain should be reported to your provider as an indication of lithium toxicity."While weight gain can be a side effect of some medications, it's not a specific indicator of lithium toxicity. Lithium toxicity is characterized by a range of symptoms including tremors, confusion, nausea, vomiting, and excessive thirst, among others.
D. "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium."
"Your provider may prescribe a diuretic if you have trouble urinating while taking lithium." Diuretics are generally not recommended with lithium because they can increase the risk of lithium toxicity. Lithium can affect kidney function, and using diuretics may exacerbate this effect. The client should be advised not to use diuretics without consulting their healthcare provider.
Full Explanation
Lithium is a commonly used medication for treating bipolar disorder, and therapeutic drug monitoring is crucial to ensure its effectiveness and prevent potential toxicity. Monitoring the client's lithium levels in the blood is important because lithium has a narrow therapeutic range, meaning that levels that are too low might not provide the desired therapeutic effect, while levels that are too high can lead to toxicity.
B) "This medication is addictive, so you will need to discontinue it in six months."
Lithium is not considered addictive. It's important to provide accurate information about the nature of the medication to avoid unnecessary concerns.
C) "Weight gain should be reported to your provider as an indication of lithium toxicity."
While weight gain can be a side effect of some medications, it's not a specific indicator of lithium toxicity. Lithium toxicity is characterized by a range of symptoms including tremors, confusion, nausea, vomiting, and excessive thirst, among others.
D) "Your provider may prescribe a diuretic if you have trouble urinating while taking lithium."
Diuretics are generally not recommended with lithium because they can increase the risk of lithium toxicity. Lithium can affect kidney function, and using diuretics may exacerbate this effect. The client should be advised not to use diuretics without consulting their healthcare provider.
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
A. Fine hand tremors and pill rolling
Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.
B. Urinary retention and constipation
Urinary retention and constipation:Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.
C. Facial grimacing and eye blinking
Facial grimacing and eye blinking: Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.
D. Involuntary pelvic rocking and hip thrusting movements
Involuntary pelvic rocking and hip thrusting movements: TD often includes repetitive, purposeless movements of the limbs, trunk, and pelvis.
E. Tongue thrusting and lip-smacking:
Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.
Full Explanation
Fine hand tremors and pill rolling are not indicative of tardive dyskinesia. These symptoms are more commonly associated with other neurological or movement disorders.
B. Urinary retention and constipation:
Urinary retention and constipation are not symptoms of tardive dyskinesia. These symptoms are more related to anticholinergic effects of certain medications.
C. Facial grimacing and eye blinking:
Facial grimacing and repetitive, involuntary movements such as eye blinking are characteristic of tardive dyskinesia. These abnormal movements of the face and eyes are commonly seen in individuals who have been on long-term antipsychotic medications, especially older ones like haloperidol.
D. Involuntary pelvic rocking and hip thrusting movements:
TD often includes repetitive, purposeless movements of the limbs, trunk, and pelvis.
E. Tongue thrusting and lip-smacking:
Tongue thrusting and lip-smacking are classic symptoms of tardive dyskinesia. These repetitive, involuntary movements involving the mouth and tongue are often observed in individuals who have been on antipsychotic medications for an extended period of time.