Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
A. Remain with the client.
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give to client a PRN sleeping medication,
Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed.
Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client.
This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Mental Health Proctored Exam. Take the full exam now
Full Explanation
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication:
Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed:
Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client:
Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
Similar Questions
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
A. Remain with the client.
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication.
Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed.
Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client
This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
Full Explanation
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication:
Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed:
Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client:
Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?
A. "You've been feeling that your life has no meaning."
This response reflects active listening and acknowledges the client's emotions. It reflects the client's feelings and encourages them to express more about their emotions and thoughts. It shows empathy and understanding, which can help build trust and rapport.
B. "You have a great deal to live for."
"You have a great deal to live for" may seem dismissive and does not address the client's current feelings of worthlessness.
C. "It's not unusual for depressed people to feel that way."
"It's not unusual for depressed people to feel that way" can come across as minimizing the client's unique experience and does not provide support or encourage further discussion.
D. "Why do you feel you are worthless?"
"Why do you feel you are worthless?" might make the client feel defensive or overwhelmed, and it does not offer the same level of empathy and support as reflecting their feelings would.
Full Explanation
A. "You've been feeling that your life has no meaning."This response reflects active listening and acknowledges the client's emotions. It reflects the client's feelings and encourages them to express more about their emotions and thoughts. It shows empathy and understanding, which can help build trust and rapport.
B. "You have a great deal to live for" may seem dismissive and does not address the client's current feelings of worthlessness.
C. "It's not unusual for depressed people to feel that way" can come across as minimizing the client's unique experience and does not provide support or encourage further discussion.
D. "Why do you feel you are worthless?" might make the client feel defensive or overwhelmed, and it does not offer the same level of empathy and support as reflecting their feelings would.
A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase 1 week ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?
A. Speak to the provider about adding an MAOI to the current medication regimen.
This action might be premature. MAOIs (Monoamine Oxidase Inhibitors) are a class of antidepressants with specific dietary and medication interactions. They are typically considered when other classes of antidepressants have not been effective. It's important to exhaust other options before considering a switch to MAOIs.
B. Explain that antidepressants often take several weeks to be fully effective.
This is an appropriate response. Antidepressants, including citalopram, can take several weeks to show their full therapeutic effects. It's common for some symptoms to improve before others. Educating the client about the delayed onset of action is important to manage their expectations.
C. Tell the client that the provider will need to change citalopram to a different medication.
It might be too early to consider changing the medication after just two weeks, especially since the client reports an improved appetite. Changes in dosage or medication should ideally be discussed with the provider after an adequate trial period.
D. Recommend a sleep study be done on the client
While sleep problems can be associated with depression, it might not be the most appropriate next step based solely on the information provided. It's more important to address the ongoing depressive symptoms before focusing solely on sleep.
Full Explanation
This action might be premature. MAOIs (Monoamine Oxidase Inhibitors) are a class of antidepressants with specific dietary and medication interactions. They are typically considered when other classes of antidepressants have not been effective. It's important to exhaust other options before considering a switch to MAOIs.
B. Explain that antidepressants often take several weeks to be fully effective:
Explanation: Correct Answer. This is an appropriate response. Antidepressants, including citalopram, can take several weeks to show their full therapeutic effects. It's common for some symptoms to improve before others. Educating the client about the delayed onset of action is important to manage their expectations.
C. Tell the client that the provider will need to change citalopram to a different medication:
Explanation: It might be too early to consider changing the medication after just two weeks, especially since the client reports an improved appetite. Changes in dosage or medication should ideally be discussed with the provider after an adequate trial period.
D. Recommend a sleep study be done on the client:
Explanation: While sleep problems can be associated with depression, it might not be the most appropriate next step based solely on the information provided. It's more important to address the ongoing depressive symptoms before focusing solely on sleep.
