Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a client who is admitted to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
A. "It's okay to feel afraid. Let's talk about what you are afraid of."
The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.
B. "Your doctor is a great surgeon. You will be fine."
"Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.
C. "Don't worry. The important thing is you have now quit smoking."
"Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.
D. "I understand your fears. I was a smoker also."
"I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.
Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.
Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.
Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.
Similar Questions
A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?
A. "Disulfiram will prevent my cravings for alcohol."
"Disulfiram will prevent my cravings for alcohol," is incorrect because disulfiram works by creating a very unpleasant reaction when the client drinks alcohol and is not a medication for preventing cravings.
B. "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage."
"It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage," is incorrect because Vitamin C is not indicated for liver disease related to alcohol use disorder and is not effective in preventing it.
C. "Withdrawal symptoms should last about 5 to 7 days once they begin."
"Withdrawal symptoms should last about 5 to 7 days once they begin," is incorrect because withdrawal symptoms can last for several days or even weeks, depending on the severity of the alcohol use disorder.
D. "I should expect hand tremors to start less than 24 hours after I stop drinking."
The client should expect hand tremors to start less than 24 hours after they stop drinking when reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder.
Full Explanation
The client should expect hand tremors to start less than 24 hours after they stop drinking when reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder.
Choice A, "Disulfiram will prevent my cravings for alcohol," is incorrect because disulfiram works by creating a very unpleasant reaction when the client drinks alcohol and is not a medication for preventing cravings.
Choice B, "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage," is incorrect because Vitamin C is not indicated for liver disease related to alcohol use disorder and is not effective in preventing it.
Choice C, "Withdrawal symptoms should last about 5 to 7 days once they begin," is incorrect because withdrawal symptoms can last for several days or even weeks, depending on the severity of the alcohol use disorder.
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
A. Identify support groups in the community for long-term treatment.
Referring the client to a mental health care provider for evaluation and treatment.
B. Assist the client to identify negative effects of chemical dependency.
This may be necessary but does not address the priority concern of suicidal risk.
C. Determine the presence and degree of suicidal risk.
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment
D. Refer client to mental health care provider for evaluation and treatment.
This is animportant intervention but is not the priority at this time. Assisting the client to identify the negative effects of chemical dependency
Full Explanation
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.
choice A and referring the client to a mental health care provider for evaluation and treatment.
choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.
choice B may be necessary but does not address the priority concern of suicidal risk.
A nurse is caring for a patient who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
A. Hypotension
This is not an answer because hypotension is a later sign of shock 2.
B. Narrowing pulse pressure
Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.
C. Decreased level of consciousness
This is not an answer because a decreased level of consciousness is also a later sign of shock .
D. Anuria
This is not an answer because anuria, or the absence of urine production, is also a later sign of shock
Full Explanation
Narrowing pulse pressure is an early indicator that shock is developing 1. Pulse pressure is the difference between systolic and diastolic blood pressure. As shock progresses, the pulse pressure narrows due to a decrease in systolic blood pressure and an increase in diastolic blood pressure.
Choice A is not an answer because hypotension is a later sign of shock 2.
Choice C is not an answer because a decreased level of consciousness is also a later sign of shock.
Choice D is not an answer because anuria, or the absence of urine production, is also a later sign of shock