Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following actions should the nurse take first?
A. Ask the client to place their feet on the floor.
B. Ask the client to sit on the edge of the bed for 2 min.
C. Ask the client to stand for 5 seconds.
D. Ask the client to march in place.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 240 Final Proctored Exam. Take the full exam now
Full Explanation
Similar Questions
A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss.
The nurse should identify that the client has manifestations of which of the following types of grief?
A. Prolonged grief.
Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.
B. Uncomplicated grief.
Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.
C. Anticipatory grief.
Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.
D. Disenfranchised grief.
Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.
Full Explanation
Choice A rationale:
Prolonged grief is characterized by an extended period of mourning and difficulty in accepting the loss. This type of grief is often associated with intense emotional pain and can last for an extended period, beyond what is considered a normal grieving process. In this scenario, the client's inability to accept the loss of their partner after 3 years is indicative of prolonged grief.
Choice B rationale:
Uncomplicated grief refers to a normal grieving process that follows a loss. It typically involves feelings of sadness, anger, and sorrow, but the individual can eventually accept the loss and continue with their life. The client in the scenario is experiencing prolonged and complicated grief, which does not fit the definition of uncomplicated grief.
Choice C rationale:
Anticipatory grief occurs when individuals start grieving before the actual loss takes place, often seen in situations where a loved one has a terminal illness, and the family begins to mourn the eventual loss. The client in the scenario is not experiencing anticipatory grief, as the loss has already occurred.
Choice D rationale:
Disenfranchised grief refers to grief that is not openly acknowledged or socially supported. It occurs when an individual's loss is not recognized or validated by others, such as in the case of the loss of a same-sex partner, a pet, or a non-traditional relationship. In this scenario, the client's grief is not disenfranchised; it is prolonged and complicated.
A nurse is teaching a class about Kohlberg's theory of moral development.
The nurse should instruct that which of the following stages involves challenging rules that impinge on the rights of others?
A. Social contract.
Kohlberg's theory of moral development includes several stages, and in the stage of the social contract, individuals begin to challenge rules and laws that they believe infringe upon the rights of others. This stage is characterized by the development of a sense of justice and social responsibility. Individuals in this stage may question laws and rules that they see as unjust and work towards changing them in favor of the greater good.
B. Law and order.
Law and order is a stage in Kohlberg's theory where individuals prioritize following the established laws and rules of society. They may not necessarily challenge these rules, as their primary concern is maintaining order and obedience to authority.
C. Punishment and obedience.
Punishment and obedience is one of the earlier stages in Kohlberg's theory, where individuals focus on avoiding punishment and obeying authority figures. This stage does not involve challenging rules for the sake of protecting the rights of others.
D. Good boy-nice girl.
Good boy-nice girl is a stage where individuals seek approval and avoid disapproval from others. They tend to conform to societal expectations and do not necessarily challenge rules that may impinge on the rights of others.
Full Explanation
Choice A rationale:
Kohlberg's theory of moral development includes several stages, and in the stage of the social contract, individuals begin to challenge rules and laws that they believe infringe upon the rights of others. This stage is characterized by the development of a sense of justice and social responsibility. Individuals in this stage may question laws and rules that they see as unjust and work towards changing them in favor of the greater good.
Choice B rationale:
Law and order is a stage in Kohlberg's theory where individuals prioritize following the established laws and rules of society. They may not necessarily challenge these rules, as their primary concern is maintaining order and obedience to authority.
Choice C rationale:
Punishment and obedience is one of the earlier stages in Kohlberg's theory, where individuals focus on avoiding punishment and obeying authority figures. This stage does not involve challenging rules for the sake of protecting the rights of others.
Choice D rationale:
Good boy-nice girl is a stage where individuals seek approval and avoid disapproval from others. They tend to conform to societal expectations and do not necessarily challenge rules that may impinge on the rights of others.
A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention.
The nurse should include which of the following as an example of secondary prevention?
A. A client who has a family history of breast cancer is scheduled for a mammogram.
Secondary prevention involves early detection and intervention to prevent the progression of a disease. In the case of breast cancer, a mammogram is a secondary prevention measure because it aims to detect cancer at an early stage, especially in individuals with a family history of the disease. Early detection can lead to timely treatment and improved outcomes.
B. A client who has heart failure is scheduled for an echocardiogram.
Echocardiograms are typically used to assess the function of the heart and diagnose existing heart conditions. While it is a valuable diagnostic tool, it is not an example of secondary prevention, which is focused on early detection and prevention of disease.
C. A client is scheduled to receive an influenza vaccination.
Influenza vaccination is an example of primary prevention, as it aims to prevent the initial occurrence of the disease by providing immunity against the influenza virus. It is not considered a form of secondary prevention.
D. A client who is asymptomatic is not scheduled for a series of tests.
Not scheduling a series of tests for an asymptomatic client does not fit the definition of secondary prevention. Secondary prevention involves screening and early detection in individuals at risk or with early signs of a disease to prevent its progression. An asymptomatic client without known risk factors may not require such testing as a preventive measure.
Full Explanation
Choice A rationale:
Secondary prevention involves early detection and intervention to prevent the progression of a disease. In the case of breast cancer, a mammogram is a secondary prevention measure because it aims to detect cancer at an early stage, especially in individuals with a family history of the disease. Early detection can lead to timely treatment and improved outcomes.
Choice B rationale:
Echocardiograms are typically used to assess the function of the heart and diagnose existing heart conditions. While it is a valuable diagnostic tool, it is not an example of secondary prevention, which is focused on early detection and prevention of disease.
Choice C rationale:
Influenza vaccination is an example of primary prevention, as it aims to prevent the initial occurrence of the disease by providing immunity against the influenza virus. It is not considered a form of secondary prevention.
Choice D rationale:
Not scheduling a series of tests for an asymptomatic client does not fit the definition of secondary prevention. Secondary prevention involves screening and early detection in individuals at risk or with early signs of a disease to prevent its progression. An asymptomatic client without known risk factors may not require such testing as a preventive measure.