Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who reports hearing voices. Which of the following statements should the nurse make first?
A. "Let's take a walk outside to see if the voices you are hearing will stop."
B. "Can you listen to me instead of the voices you are hearing?"
C. "Are the voices you are hearing telling you to hurt yourself or someone else?"
Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.
D. "I know that the voices are real to you, but I do not hear them."
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.
Similar Questions
A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?
A. "Why do you feel the staff is the FBI?"
B. "What makes you think the staff is following you?"
C. "This must be very frightening for you. Let's talk more about it."
Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniquesto empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in theclient's reality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.
D. "The psychiatric staff is not FBI. They are here to help you."
Full Explanation
The correct answer is C. Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniques to empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in the client's reality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.
A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?
A. Muscle cramps
Hyponatremia is a condition where sodium levels in the blood are lower than normal, which can cause water to move into body cells and make them swell. This can affect muscle cells and cause cramps, spasms or weakness. The other options are not typical signs of hyponatremia.
B. Constipation
C. Blurred vision
D. Hypertension
Full Explanation
The correct answer is A. Muscle cramps. Hyponatremia is a condition where sodium levels in the blood are lower than normal, which can cause water to move into body cells and make them swell. This can affect muscle cells and cause cramps, spasms or weakness. The other options are not typical signs of hyponatremia.
A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching?
A. “I will wait 15 minutes before taking a second tablet."
B. "I will swallow the tablet for faster absorption."
C. "I should stop taking the medication if I get a headache."
D. "I should expect pain relief in 1 to 3 minutes."
I should expect pain relief in 1 to 3 minutes. Sublingual nitroglycerin tablets are placed under the tongue and dissolve quickly to relieve chest pain caused by angina. The medication works by dilating blood vessels and improving blood flow to the heart. The onset of action is usually within 1 to 3 minutes.
Full Explanation
The correct answer is D. I should expect pain relief in 1 to 3 minutes. Sublingual nitroglycerin tablets are placed under the tongue and dissolve quickly to relieve chest pain caused by angina. The medication works by dilating blood vessels and improving blood flow to the heart. The onset of action is usually within 1 to 3 minutes.