Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?.
A. A client who has bipolar disorder and is continuously pacing at the end of the hall.
A rationale: While pacing can indicate anxiety, this client is not currently a threat to themselves or others.
B. A client who is standing in her room, yelling obscenities and throwing her clothes.
B rationale: This client is exhibiting aggressive behavior and could potentially harm themselves or damage property.
C. A client in the dayroom who is screaming at other clients about what is on the television.
C rationale: Although this client’s behavior is disruptive, it is not immediately dangerous.
D. A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
D rationale: This client’s repeated requests indicate anxiety, but they are not in immediate danger.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
While pacing can indicate anxiety, this client is not currently a threat to themselves or others.
Choice B rationale:
This client is exhibiting aggressive behavior and could potentially harm themselves or damage property.
Choice C rationale:
Although this client’s behavior is disruptive, it is not immediately dangerous.
Choice D rationale:
This client’s repeated requests indicate anxiety, but they are not in immediate danger.
Similar Questions
A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?.
A. Encourage the client to visit with the sibling.
A rationale: It’s not appropriate to pressure the client into seeing visitors.
B. Tell the sibling the client does not want visitors.
B rationale: It’s important to respect the client’s wishes and communicate them to the sibling.
C. Arrange for the sibling to visit the client in the dayroom.
C rationale: This could potentially cause distress for the client.
D. Refer the sibling to the client's provider.
D rationale: While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
Full Explanation
Choice A rationale:
It’s not appropriate to pressure the client into seeing visitors.
Choice B rationale:
It’s important to respect the client’s wishes and communicate them to the sibling.
Choice C rationale:
This could potentially cause distress for the client.
Choice D rationale:
While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
A nurse is collecting data from an adult client in an outpatient mental health clinic.
The nurse should identify which of the following events as a potential cause of a maturational crisis?.
A. Motor-vehicle crash.
A rationale: A motor-vehicle crash is an adventitious crisis, not a maturational one.
B. A child leaving for college.
B rationale: A child leaving for college is a normal developmental milestone that can cause stress.
C. Loss of job.
C rationale: Loss of a job is a situational crisis, not a maturational one.
D. Divorce.
D rationale: Divorce is a situational crisis, not a maturational one.
Full Explanation
Choice A rationale:
A motor-vehicle crash is an adventitious crisis, not a maturational one.
Choice B rationale:
A child leaving for college is a normal developmental milestone that can cause stress.
Choice C rationale:
Loss of a job is a situational crisis, not a maturational one.
Choice D rationale:
Divorce is a situational crisis, not a maturational one.
A nurse is caring for a client who has a new diagnosis of cancer.
The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.
A. Suppression
A rationale: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.
B. Reaction formation.
B rationale: Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.
C. Splitting.
C rationale: Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.
D. Projection.
D rationale: Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.
Full Explanation
Choice A rationale:
Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.
Choice B rationale:
Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.
Choice C rationale:
Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.
Choice D rationale:
Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.