Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from an older adult client who was admitted with heart failure.
The nurse should report which of the following findings to the provider as an indication of delirium? .
A. Consistent state of depression
A rationale: A consistent state of depression is not indicative of delirium, but rather a mood disorder.
B. Fluctuating level of orientation.
B rationale: Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
C. Demonstrates obsessive behaviors.
C rationale: Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
D. Family report of gradual memory loss.
D rationale: Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
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:
A consistent state of depression is not indicative of delirium, but rather a mood disorder.
Choice B rationale:
Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.
Choice C rationale:
Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.
Choice D rationale:
Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.
Similar Questions
A nurse is caring for an adolescent who was recently sexually assaulted.
Which of the following statements by the adolescent's guardian represents the presence of a positive support system? .
A. "I anticipate that my child will feel some self-blame.”.
Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
B. "I will have to do all I can to monitor my child's relationships.”. .
While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
C. "I should encourage my child to focus solely on the future.”. .
Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
D. "I can encourage my child to think about what they did that allowed this event to happen.”. .
Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.
Full Explanation
The correct answer is choice A: "I anticipate that my child will feel some self-blame."
Choice A rationale: Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
Choice B rationale: While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
Choice C rationale: Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
Choice D rationale: Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.
A nurse is assisting with reminiscence therapy for a group of older adult clients.
Which of the following strategies should the nurse implement? .
A. Discussing childhood memories during group therapy
A rationale: Discussing childhood memories during group therapy is a key component of reminiscence therapy. It helps older adults recall past experiences and can improve their mood and cognitive function.
B. Playing board games with other clients to enhance cognition.
B rationale: Playing board games can enhance cognition, but it’s not specific to reminiscence therapy.
C. Making a unit calendar to promote orientation.
C rationale: Making a unit calendar promotes orientation, but it’s not part of reminiscence therapy.
D. Encouraging thought-stopping to block undesirable thoughts.
D rationale: Encouraging thought-stopping can help block undesirable thoughts, but it’s not a strategy used in reminiscence therapy.
Full Explanation
Choice A rationale:
Discussing childhood memories during group therapy is a key component of reminiscence therapy. It helps older adults recall past experiences and can improve their mood and cognitive function.
Choice B rationale:
Playing board games can enhance cognition, but it’s not specific to reminiscence therapy.
Choice C rationale:
Making a unit calendar promotes orientation, but it’s not part of reminiscence therapy.
Choice D rationale:
Encouraging thought-stopping can help block undesirable thoughts, but it’s not a strategy used in reminiscence therapy.
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder.
Which of the following actions should the nurse take first? .
A. Administer an antianxiety medication
A rationale: Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.
B. Calculate the client's score on the Hamilton Rating Scale for Anxiety.
B rationale: Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.
C. Explain the use of response prevention to the client.
C rationale: Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.
D. Discuss the benefits of relaxation exercises with the client.
D rationale: Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.
Full Explanation
Choice A rationale:
Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.
Choice B rationale:
Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.
Choice C rationale:
Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.
Choice D rationale:
Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.