Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
A. Place the client in seclusion when he exhibits signs of anxiety.
Incorrect. Placing the client in seclusion is not an appropriate intervention for managing mania.
B. Encourage the client to spend time in the dayroom.
Incorrect. Encouraging the client to spend time in the dayroom may exacerbate symptoms of mania by providing more stimulation.
C. Encourage the client to take frequent rest periods.
Correct. Encouraging the client to take frequent rest periods helps prevent overactivity and exhaustion, common in manic episodes.
D. Withdraw the client's TV privileges if he does not attend group therapy.
Incorrect. Withdrawing privileges is not directly related to managing manic symptoms and may not be therapeutic.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Predictor Proctored Exam. Take the full exam now
Full Explanation
A. Incorrect. Placing the client in seclusion is not an appropriate intervention for managing mania.
B. Incorrect. Encouraging the client to spend time in the dayroom may exacerbate symptoms of mania by providing more stimulation.
C. Correct. Encouraging the client to take frequent rest periods helps prevent overactivity and exhaustion, common in manic episodes.
D. Incorrect. Withdrawing privileges are not directly related to managing manic symptoms and may not be therapeutic.
Similar Questions
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
A. Talk with the client during her feeding.
A. Incorrect. While it's important to maintain social interaction with the client, avoiding excessive conversation during feeding is recommended. Distractions can interfere with the client's ability to focus on swallowing and increase the risk of aspiration.
B. Discourage the client from coughing during feedings.
B. Incorrect. Coughing is a natural reflex that helps to clear the airway of any material that may have been aspirated. Discouraging coughing could potentially lead to a more serious problem.
C. Sit at or below the client's eye level during feedings.
C. Correct. Sitting at or below the client's eye level provides a clearer view of the food and helps the client maintain control over their swallowing. This can reduce the risk of aspiration.
D. Instruct the client to lift her chin when swallowing.
D. Incorrect. Lifting the chin can actually increase the risk of aspiration by narrowing the opening to the trachea (windpipe). It's generally recommended to avoid lifting the chin during swallowing.
Full Explanation
- A. Incorrect. While it's important to maintain social interaction with the client, avoiding excessive conversation during feeding is recommended. Distractions can interfere with the client's ability to focus on swallowing and increase the risk of aspiration.
- B. Incorrect. Coughing is a natural reflex that helps to clear the airway of any material that may have been aspirated. Discouraging coughing could potentially lead to a more serious problem.
- C. Correct. Sitting at or below the client's eye level provides a clearer view of the food and helps the client maintain control over their swallowing. This can reduce the risk of aspiration.
- D. Incorrect. Lifting the chin can actually increase the risk of aspiration by narrowing the opening to the trachea (windpipe). It's generally recommended to avoid lifting the chin during swallowing.
A nurse is caring for an adolescent who has hyperthermia. Which of the following actions should the nurse take?
A. Cover the adolescent with a thermal blanket.
Incorrect. Covering the adolescent with a thermal blanket may worsen hyperthermia.
B. Initiate seizure precautions.
Correct. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Submerge the adolescent's feet in ice water.
Incorrect. Submerging the feet in ice water is not recommended due to the risk of causing shock.
D. Administer oral acetaminophen.
Incorrect. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
Full Explanation
A. Incorrect. Covering the adolescent with a thermal blanket may worsen hyperthermia.
B. Correct. Hyperthermia can cause neurological complications, such as seizures, confusion, or coma. Therefore, the nurse should initiate seizure precautions for an adolescent who has hyperthermia to prevent injury and protect the airway.
C. Incorrect. Submerging the feet in ice water is not recommended due to the risk of causing shock.
D. Incorrect. Administering oral acetaminophen would not be effective for hyperthermia caused by non-infectious factors, such as heat exposure or medications. Acetaminophen lowers the body temperature by reducing the hypothalamic set point, which is not altered in hyperthermia. Additionally, oral medications may be difficult to swallow or absorb in a hyperthermic patient.
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention?
A. Using an electronic messaging system to remind clients when to take medications
Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention, as it aims to prevent the development of complications.
B. Helping clients understand health screenings covered by their insurance plans
Incorrect. Helping clients understand health screenings covered by their insurance plans can be considered primary or secondary prevention, depending on the context.
C. Providing clients with information about the benefits of exercise
Incorrect. Providing clients with information about the benefits of exercise is an example of health promotion, which is also a component of primary prevention.
D. Educating clients about contraindications to specific immunizations
Educating clients about contraindications to specific immunizations also falls under tertiary prevention, which aims to minimize the impact of an illness or condition that is already present.
Full Explanation
A. Using an electronic messaging system to remind clients when to take medications is an example of tertiary prevention, as it aims to prevent the development of complications.
B. Helping clients understand health screenings covered by their insurance plans can be considered primary or secondary prevention, depending on the context.
C. Incorrect. Providing clients with information about the benefits of exercise is an example of health promotion, which is also a component of primary prevention.
D. Educating clients about contraindications to specific immunizations falls under tertiary prevention, which aims to minimize the impact of an illness or condition that is already present.