Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client diagnosed with a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
A. "You are not responsible for your mother's stroke, but many people in your situation feel this way.”
This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.
B. "Your mother will be fine. You shouldn't worry so much.”
This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.
C. "Why do you blame yourself? You could not have prevented the stroke.”
Asking why he blames himself and stating he could not have prevented the stroke (Choice C) may come across as confrontational and dismissive of his feelings. It's important to provide support and understanding rather than challenging his emotions.
D. "So, it seems that you feel responsible for what happened to your mother.”
This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 133 Mental Health Final Proctored Exam Summer (2023). Take the full exam now
Full Explanation
The correct answer is choice d. "So, it seems that you feel responsible for what happened to your mother.”
Choice A rationale: This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.
Choice B rationale: This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.
Choice C rationale: This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.
Choice D rationale: This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.
Similar Questions
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication the client is in the denial phase of the grief process?
A. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!”
This statement reflects anger and frustration, which are characteristic of the anger stage of grief. The individual is expressing disbelief in the doctor's competence but is not denying the reality of their diagnosis.
B. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.”
Feeling fatigued and lacking energy can be a physical manifestation of the grief process, but it does not specifically indicate denial. This statement could reflect depression or physical symptoms associated with the client's medical condition.
C. "The doctor has been so good to me. I know he has tried everything he can. It is just my time.”
Expressing gratitude and understanding for the doctor's efforts indicates acceptance, not denial. This statement suggests that the client has reached a point of acknowledging the doctor's attempts to provide care.
D. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.”
This statement indicates denial as the client doubts the doctor's prognosis and believes the doctor is exaggerating. Denial is a common initial reaction where the individual struggles to accept the reality of their diagnosis, instead choosing to believe it is not as severe.
Full Explanation
The correct answer is Choice D.
Choice A rationale: This statement reflects anger and frustration, which are characteristic of the anger stage of grief. The individual is expressing disbelief in the doctor's competence but is not denying the reality of their diagnosis.
Choice B rationale: This statement indicates acceptance and acknowledgment of the physical effects of the disease. The client recognizes their lack of energy but is not denying their condition, suggesting they are in a more advanced stage of the grieving process.
Choice C rationale: This statement reflects acceptance of the situation and gratitude towards the doctor. The client acknowledges the efforts made by the medical team and recognizes the inevitability of their condition, indicating they are in the acceptance stage of grief.
Choice D rationale: This statement indicates denial as the client doubts the doctor's prognosis and believes the doctor is exaggerating. Denial is a common initial reaction where the individual struggles to accept the reality of their diagnosis, instead choosing to believe it is not as severe.
According to Bowen's theoretical approach to therapy, which of the following should the nurse recognize as a concept of a functional family interaction pattern?
A. Marital skew.
Marital skew is not a concept associated with Bowen's family systems theory. It does not correspond to any recognized pattern in this theoretical approach.
B. Sibling position.
Sibling position is an important concept in Bowen's family systems theory. It refers to the birth order of siblings within a family and how this birth order can influence the roles and dynamics within the family unit.
C. Pseudomutuality.
Pseudomutuality is not a concept of Bowen's family systems theory. This term does not align with the terminology or principles of this theoretical approach.
D. Double-bind communication.
Double-bind communication is a concept introduced by Gregory Bateson and is associated with the communication patterns within dysfunctional families. While it is related to family interactions, it is not specifically attributed to Bowen's theoretical approach.
Full Explanation
The correct answer is choice: B. Sibling position.
Choice A rationale:
Marital skew is not a concept associated with Bowen's family systems theory. It does not correspond to any recognized pattern in this theoretical approach.
Choice B rationale:
Sibling position is an important concept in Bowen's family systems theory. It refers to the birth order of siblings within a family and how this birth order can influence the roles and dynamics within the family unit.
Choice C rationale:
Pseudomutuality is not a concept of Bowen's family systems theory. This term does not align with the terminology or principles of this theoretical approach.
Choice D rationale:
Double-bind communication is a concept introduced by Gregory Bateson and is associated with the communication patterns within dysfunctional families. While it is related to family interactions, it is not specifically attributed to Bowen's theoretical approach.
A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
A. "If a dose is missed, double the next dose of medication."
“If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.
B. "This medication may increase your blood pressure."
“This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.
C. "Do not eat aged cheeses while taking this medication."
“Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.
D. "Use a dependable form of contraception while taking this medication.”
“Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.
Full Explanation
The correct answer is D:
Choice A reason: “If a dose is missed, double the next dose of medication.” This statement is incorrect. Doubling up on a dose can lead to an overdose and serious side effects. Patients are advised to take the missed dose as soon as they remember unless it’s almost time for the next dose.
Choice B reason: “This medication may increase your blood pressure.” Alprazolam is known to have a sedative effect, which can lower blood pressure rather than increase it. Therefore, this statement is not typically accurate.
Choice C reason: “Do not eat aged cheeses while taking this medication.” This dietary restriction is associated with monoamine oxidase inhibitors (MAOIs), which are a different class of medications used to treat depression. Alprazolam does not interact with tyramine-rich foods like aged cheeses, so this statement is not applicable.
Choice D reason: “Use a dependable form of contraception while taking this medication.” Alprazolam falls under FDA Pregnancy Category D, which means there is positive evidence of human fetal risk, but the potential benefits may warrant use in pregnant women despite the risks. Therefore, it is important to use reliable contraception to prevent pregnancy while taking this medication.