Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is contributing to the plan of care for a client who has acute delirium.
Which of the following interventions should the nurse include in the plan of care? .
A. Discourage visitation from the client's family
A rationale: Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.
B. Provide a high-stimulation environment for the client.
B rationale: A high-stimulation environment could overstimulate the client and worsen delirium.
C. Limit the client's need to make decisions.
C rationale: Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.
D. Keep the client's room dark at night.
D rationale: Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.
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:
Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.
Choice B rationale:
A high-stimulation environment could overstimulate the client and worsen delirium.
Choice C rationale:
Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.
Choice D rationale:
Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.
Similar Questions
A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder.
Which of the following statements by the parent indicates an understanding of the redirection technique? .
A. "I should re-engage my child in an appropriate activity.”.
A rationale: Re-engaging the child in an appropriate activity is a good example of the redirection technique.
B. "I should move closer to my child when they are agitated.”. .
B rationale: Moving closer to the child when they are agitated could escalate the situation rather than calm it.
C. "I should use role-playing to enhance new behavioral skills.”. .
C rationale: Using role-playing to enhance new behavioral skills is a good strategy, but it is not an example of the redirection technique.
D. "I should ignore attention-seeking behaviors.”. . .
D rationale: Ignoring attention-seeking behaviors could lead to an escalation of those behaviors as the child seeks attention.
Full Explanation
Choice A rationale:
Re-engaging the child in an appropriate activity is a good example of the redirection technique.
Choice B rationale:
Moving closer to the child when they are agitated could escalate the situation rather than calm it.
Choice C rationale:
Using role-playing to enhance new behavioral skills is a good strategy, but it is not an example of the redirection technique.
Choice D rationale:
Ignoring attention-seeking behaviors could lead to an escalation of those behaviors as the child seeks attention.
A nurse is collecting data from a client who has schizophrenia.
Which of the following client statements indicates that the client is experiencing a command hallucination? .
A. "The aliens are going to abduct me tonight.”.
A rationale: This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.
B. "The voices told me to quit eating the food here.”. .
B rationale: This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.
C. "Are you planning to kill me?" .
C rationale: This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.
D. "Can you see these spiders crawling all over me?" .
D rationale: This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.
Full Explanation
Choice A rationale:
This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.
Choice B rationale:
This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.
Choice C rationale:
This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.
Choice D rationale:
This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.
A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.
To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication? .
A. Liver enzymes
A rationale: While liver enzymes are important to monitor for many medications, they are not typically affected by lithium.
B. Uric acid.
B rationale: Uric acid levels are not typically affected by lithium.
C. Sodium level.
C rationale: Lithium can affect the sodium levels in the body, making it important to monitor these levels while taking this medication.
D. Erythrocyte sedimentation rate.
D rationale: Erythrocyte sedimentation rate is not typically affected by lithium.
Full Explanation
Choice A rationale:
While liver enzymes are important to monitor for many medications, they are not typically affected by lithium.
Choice B rationale:
Uric acid levels are not typically affected by lithium.
Choice C rationale:
Lithium can affect the sodium levels in the body, making it important to monitor these levels while taking this medication.
Choice D rationale:
Erythrocyte sedimentation rate is not typically affected by lithium.