Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is completing an admission assessment for a client who has obsessive- compulsive disorder and is becoming increasingly anxious. Which of the following actions should the nurse take first?
A. Teach the client about manifestations of anxiety.
Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.
B. Complete the client's assessment.
Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.
C. Provide reassurance of safety to the client.
Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.
D. Administer an anti-anxiety medication to the client.
Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.
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Full Explanation
Choice A rationale:
Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.
Choice B rationale:
Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.
Choice C rationale:
Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.
Choice D rationale:
Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.
Similar Questions
A nurse is assisting the parent of a preterm newborn to perform skin-to-skin care to enhance parental bonding. Which of the following actions should the nurse take?
A. Instruct the parent to remove his shirt.
Instructing the parent to remove their shirt allows for direct skin-to- skin contact between the parent's chest and the preterm newborn, which is commonly known as kangaroo care. This technique promotes bonding, warmth, and comfort for both the parent and the newborn.
B. Place the newborn and parent in a private room that is brightly lit.
Placing the newborn and parent in a private room that is brightly lit might not be optimal for skin-to-skin care, as preterm newborns are sensitive to light and sound. A calm and dimly lit environment is preferred.
C. Place the newborn in a horizontal position in the parent's arms.
Placing the newborn in a horizontal position in the parent's arms is appropriate, as it allows for skin-to-skin contact and facilitates bonding. The newborn's head is positioned near the parent's chest to listen to the heartbeat.
D. Completely undress the newborn.
Completely undressing the newborn is not necessary for skin-to-skin care and may cause discomfort to the newborn. Keeping the newborn dressed in a diaper is sufficient.
Full Explanation
Choice A rationale:
Instructing the parent to remove their shirt allows for direct skin-to- skin contact between the parent's chest and the preterm newborn, which is commonly known as kangaroo care. This technique promotes bonding, warmth, and comfort for both the parent and the newborn.
Choice B rationale:
Placing the newborn and parent in a private room that is brightly lit might not be optimal for skin-to-skin care, as preterm newborns are sensitive to light and sound. A calm and dimly lit environment is preferred.
Choice C rationale:
Placing the newborn in a horizontal position in the parent's arms is appropriate, as it allows for skin-to-skin contact and facilitates bonding. The newborn's head is positioned near the parent's chest to listen to the heartbeat.
Choice D rationale:
Completely undressing the newborn is not necessary for skin-to-skin care and may cause discomfort to the newborn. Keeping the newborn dressed in a diaper is sufficient.
A nurse is evaluating the effectiveness of the plan of care for a client who has experienced sexual assault. Which of the following findings indicates effectiveness of the plan of care?
A. Exhibits grief response behaviors
Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.
B. States a desire for revenge
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
C. Asks for advice about making life decisions
A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.
D. Demonstrates an increase in regressive behavior
Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.
Full Explanation
Choice A rationale:
Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.
Choice B rationale:
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
Choice C rationale:
A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.
Choice D rationale:
Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.
A nurse is caring for a 19-year-old client who is dying following a motor vehicle crash. Which of the following individuals should the nurse approach first about considering organ donation?
A. The client's parent
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
B. The client's grandparent
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
C. The client's older sibling
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
D. The client's spouse
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Full Explanation
Choice A rationale:
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
Choice B rationale:
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Choice C rationale:
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
Choice D rationale:
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.