Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?
A. "How have you dealt with stress in the past?"
B. "Are you thinking of harming yourself?"
The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.
C. "Let's talk more about what you are experiencing."
D. "Tell me what makes you feel stressed."
This question is an excerpt from Nurse Dive's nursing test bank - RN Mental Health 2019 With NGN Proctored Exam. Take the full exam now
Full Explanation
The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.
Similar Questions
A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
A. "The client is just like my brother who finally overcame his habit."
Countertransference occurs when a staff member projects their own feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which can interfere with objective and empathetic care.
B. "The client asked me to go on a date with him, but I refused."
C. "The client generally shares his feelings during group therapy sessions."
D. "The client needs to accept responsibility for his substance use."
Full Explanation
Countertransference occurs when a staff member projects their own feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which can interfere with objective and empathetic care.
A nurse in an in-patient facility is caring for a client who has an anxiety disorder. Which of the following actions should the nurse take while the client is experiencing an acute panic attack?
A. Encourage the client to describe their feelings in a journal.
B. Administer a dose of atomoxetine to the client.
C. Encourage the client to watch television as a distraction.
D. Administer a dose of alprazolam to the client.
Alprazolam is a benzodiazepine that can provide rapid relief of anxiety symptoms during a panic attack. Atomoxetine is a selective norepinephrine reuptake inhibitor that is used to treat attention-deficit/hyperactivity disorder, not anxiety disorders. Journaling and watching television are not appropriate interventions during an acute panic attack, as they do not address the client's physiological and psychological needs.
Full Explanation
Alprazolam is a benzodiazepine that can provide rapid relief of anxiety symptoms during a panic attack. Atomoxetine is a selective norepinephrine reuptake inhibitor that is used to treat attention-deficit/hyperactivity disorder, not anxiety disorders. Journaling and watching television are not appropriate interventions during an acute panic attack, as they do not address the client's physiological and psychological needs.
A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?
A. Ask the charge nurse to obtain informed consent.
B. Contact the facility social worker to obtain the consent.
C. Explain implied consent to the client's family.
D. Request that the client's guardian sign the consent.
The rationale is that a client who is legally incompetent cannot give informed consent, and the nurse should obtain consent from the person who has the legal authority to make decisions for the client, such as a guardian or a durable power of attorney.
Full Explanation
The rationale is that a client who is legally incompetent cannot give informed consent, and the nurse should obtain consent from the person who has the legal authority to make decisions for the client, such as a guardian or a durable power of attorney.