Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
A. Identify the clients’ coping skills.
B. Determine the cause of the client's anxiety.
C. Ensuring that the client feels safe.
D. Protecting the client from injury
This question is an excerpt from Nurse Dive's nursing test bank - Mental Health - Proctored Exam 2. Take the full exam now
Full Explanation
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.
Similar Questions
According to Erickson’s Psychological theory of development, chronic illness can interfere with which stage of development in a 6-year-old scholar kid?
A. Trust versus mistrust
B. Autonomy versus shame and doubt.
C. Industry versus inferiority
The Industry versus Inferiority stage occurs during the ages of 6 to 12 years old. At this stage, children start to develop a sense of competence and work towards mastering new skills. Success during this stage leads to a sense of pride, while failure leads to feelings of inferiority. Chronic illness can interfere with a child's ability to develop a sense of competence and mastery, leading to feelings of failure and inferiority. This can have a negative impact on their self-esteem and overall development.
D. Identity versus role confusion.
Full Explanation
The Industry versus Inferiority stage occurs during the ages of 6 to 12 years old. At this stage, children start to develop a sense of competence and work towards mastering new skills. Success during this stage leads to a sense of pride, while failure leads to feelings of inferiority.
Chronic illness can interfere with a child's ability to develop a sense of competence and mastery, leading to feelings of failure and inferiority. This can have a negative impact on their self-esteem and overall development.
A nurse in a substance abuse clinic is assessing a client who recently started taking disulfiram. The client reports discontinued the medication after experiencing severe nausea and vomiting. Which of the following reasons should the nurse suspect to be a likely cause of the Client’s distress?
A. The client experienced a common side effect to the medication.
Option a is incorrect because nausea and vomiting are not common side effects of disulfiram.
B. The client consumed alcohol while taking the medication.
Disulfiram is a medication used in the treatment of alcohol addiction. It works by causing unpleasant symptoms, such as nausea and vomiting, when alcohol is consumed. This medication is only effective if the client abstains from alcohol consumption while taking it. If the client consumes alcohol while taking disulfiram, they will experience severe adverse effects, including nausea and vomiting, which can be a sign of a severe reaction. Therefore, it is crucial for the nurse to suspect that the client's distress is likely caused by consuming alcohol while taking disulfiram.
C. The client demonstrated an allergic response to the medication.
Option c is incorrect because the question does not provide any information suggesting an allergic reaction.
D. The client took an overdose of the medication.
Option d is incorrect because an overdose of disulfiram would not likely cause nausea and vomiting as severe as those reported by the client.
Full Explanation
Disulfiram is a medication used in the treatment of alcohol addiction. It works by causing unpleasant symptoms, such as nausea and vomiting, when alcohol is consumed. This medication is only effective if the client abstains from alcohol consumption while taking it. If the client consumes alcohol while taking disulfiram, they will experience severe adverse effects, including nausea and vomiting, which can be a sign of a severe reaction. Therefore, it is crucial for the nurse to suspect that the client's distress is likely caused by consuming alcohol while taking disulfiram.
Option a is incorrect because nausea and vomiting are not common side effects of disulfiram.
Option c is incorrect because the question does not provide any information suggesting an allergic reaction.
Option d is incorrect because an overdose of disulfiram would not likely cause nausea and vomiting as severe as those reported by the client.
Which technique will best communicate to a patient that the registered nurse is interested in listening?
A. Restate a feeling or thought the patient has expressed.
This technique is known as reflective listening or active listening, and it involves paraphrasing what the patient has said to show that the nurse is actively listening and trying to understand the patient's feelings and thoughts. It demonstrates empathy and helps to build trust between the nurse and patient.
B. Giving advice and opinion about the patient's problem.
Option b is not effective because giving advice and opinion can convey a lack of interest in the patient's feelings and thoughts.
C. Ask a direct question, such as, “Did you feel angry?"
Option c is not ideal because it is a closed-ended question that may limit the patient's response.
D. Say "I understand what you're saying now."
Option d may also seem insincere and may not reflect a genuine interest in the patient's concerns.
Full Explanation
This technique is known as reflective listening or active listening, and it involves paraphrasing what the patient has said to show that the nurse is actively listening and trying to understand the patient's feelings and thoughts. It demonstrates empathy and helps to build trust between the nurse and patient.
Option b is not effective because giving advice and opinion can convey a lack of interest in the patient's feelings and thoughts.
Option c is not ideal because it is a closed-ended question that may limit the patient's response.
Option d may also seem insincere and may not reflect a genuine interest in the patient's concerns.
