Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a newly admitted client who has schizophrenia. Which of the following actions is the nurse's priority?
A. Determine if the client is experiencing command hallucinations.
Assessing for the presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
B. Arrange for the client to have consistent staff assignments.
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
C. Administer lorazepam to the client.
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
D. Use the client's name when talking to him.
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
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 presence of command hallucinations is a priority, as they can pose a risk to the client's safety and the safety of others.
Choice B rationale:
Consistent staff assignments can be important for clients with schizophrenia, but immediate safety concerns should take precedence.
Choice C rationale:
Administering medication is not the priority action unless there is a specific reason to do so based on the assessment.
Choice D rationale:
Using the client's name is respectful and helpful, but it is not the priority action in this scenario.
Similar Questions
A nurse is reviewing the laboratory report for a client who has acute pancreatitis. The nurse should identify that which of the following findings indicates an improvement in the client's condition?
A. Increased serum amylase
Increased serum amylase is a common finding in acute pancreatitis, and its decrease would be a positive sign. However, lipase is a more specific marker for pancreatic injury.
B. Increased C-reactive protein
Increased C-reactive protein is a marker of inflammation and would not necessarily indicate improvement in pancreatitis.
C. Decreased serum lipase
Decreased serum lipase indicates improvement in the pancreatic injury and is a positive sign.
D. Decreased platelets
Decreased platelets would not specifically indicate improvement in acute pancreatitis.
Full Explanation
Choice A rationale:
Increased serum amylase is a common finding in acute pancreatitis, and its decrease would be a positive sign. However, lipase is a more specific marker for pancreatic injury.
Choice B rationale:
Increased C-reactive protein is a marker of inflammation and would not necessarily indicate improvement in pancreatitis.
Choice C rationale:
Decreased serum lipase indicates improvement in the pancreatic injury and is a positive sign.
Choice D rationale:
Decreased platelets would not specifically indicate improvement in acute pancreatitis.
A nurse is reviewing the medical records of a group of clients who are receiving chemotherapy. The nurse should identify that which of the following clients is at greatest risk for infection?
A. A 64-year-old client who is taking estrogen supplements
Taking estrogen supplements does not significantly increase infection risk in clients receiving chemotherapy.
B. A 70-year-old client who has COPD
A 70-year-old client with chronic obstructive pulmonary disease (COPD) is at greatest risk for infection because advanced age and chronic lung disease both impair immune function and increase susceptibility to respiratory infections, especially during chemotherapy.
C. A 28-year-old client who has a left arm fracture
A left arm fracture may increase local infection risk, but it does not pose as high a systemic infection risk as COPD in an older adult.
D. A 53-year-old client who has a thin build
Having a thin build does not inherently increase infection risk in the context of chemotherapy.
Full Explanation
A. Taking estrogen supplements does not significantly increase infection risk in clients receiving chemotherapy.
B. A 70-year-old client with chronic obstructive pulmonary disease (COPD) is at greatest risk for infection because advanced age and chronic lung disease both impair immune function and increase susceptibility to respiratory infections, especially during chemotherapy.
C. A left arm fracture may increase local infection risk, but it does not pose as high a systemic infection risk as COPD in an older adult.
D. Having a thin build does not inherently increase infection risk in the context of chemotherapy.
A nurse is providing teaching about palliative care to the family of a client who is approaching death. Which of the following information should the nurse include in the teaching?
A. Awaken the client frequently throughout the day.
Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.
B. Keep the client warm by applying an electric blanket.
Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.
C. Position the client on their side with the head of bed elevated.
Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.
D. Encourage the client to eat soft foods intermittently.
Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.
Full Explanation
Choice A rationale:
Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.
Choice B rationale:
Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.
Choice C rationale:
Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.
Choice D rationale:
Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.