Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for an older adult client who has dementia.
Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).
A. Allow the client to choose among a variety of activities each day.
is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia. The nurse should provide a structured and consistent daily routine for the client.
B. Give the client one simple direction at a time.
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
C. Reinforce orientation to time, place, and person.
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
D. Establish eye contact when communicating with the client.
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
E. Refute the client’s delusions using logic.
wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.
Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.
The nurse should provide a structured and consistent daily routine for the client.
Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.
Similar Questions
A nurse is caring for a client who is immobile.
Which of the following interventions is appropriate to prevent contracture?
A. Align a trochanter wedge between the client’s legs.
because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.
B. Apply an orthotic to the client’s foot.
An orthotic is a device that supports or corrects the function of a body part. In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients. Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.
C. Place a towel roll under the client’s neck.
wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.
D. Position a pillow under the client’s knees.
pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis. Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.
E. undefined
Full Explanation
The correct answer is choice B. Applying an orthotic to the client’s foot.
An orthotic is a device that supports or corrects the function of a body part.
In this case, an orthotic can help prevent foot drop, which is a common contracture deformity in immobile patients.
Foot drop occurs when the muscles that lift the foot become weak or paralyzed, causing the foot to hang down at the ankle. An orthotic can keep the foot in a neutral position and prevent shortening of the calf muscles and Achilles tendon.
Choice A is wrong because a trochanter wedge is used to prevent external rotation of the hip, not contracture. A trochanter wedge is a triangular-shaped pillow that is placed between the legs to keep them parallel and aligned.
Choice C is wrong because a towel roll under the neck is used to maintain proper cervical alignment, not contracture. A towel roll can prevent hyperextension of the neck and support the natural curve of the spine.
Choice D is wrong because a pillow under the knees can actually cause contracture of the knee joint by keeping it in a flexed position. A pillow under the knees can also reduce blood flow to the lower extremities and increase the risk of deep vein thrombosis.
Contracture is a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen.
Contracture can limit the range of motion and function of the affected body part. Contracture can be caused by inactivity, scarring, or diseases that affect the muscles or nerves. Prevention of contractures requires early diagnosis and initiation of physical medicine approaches such as passive range of motion exercises and splinting before contractures are present or while contractures are mild.
A public health nurse working in a rural area is developing a program to improve health for the local population.
Which of the following actions should the nurse plan to take?
A. Encourage rural residents to focus health spending on tertiary health interventions.
is wrong because tertiary health interventions are not the best way to improve health for the local population. Tertiary health interventions are those that focus on treating and rehabilitating people who have already developed a disease or disability. They are more costly and less effective than primary or secondary health interventions, which aim to prevent or detect diseases early. Encouraging rural residents to focus health spending on tertiary health interventions would not address the underlying causes of poor health in the community.
B. Have a nurse from outside the community provide health lectures at the county hospital.
wrong because having a nurse from outside the community provide health lectures at the county hospital is not a culturally appropriate or accessible way to deliver health education. A nurse from outside the community may not understand the needs, values, beliefs, and practices of the rural residents, and may not be able to establish trust and rapport with them. Moreover, the county hospital may not be a convenient or comfortable location for many rural residents to attend health lectures, especially if they have transportation, financial, or time barriers. A better approach would be to involve local community members and leaders in planning and delivering health education programs that are tailored to the rural context and culture.
C. Provide anticipatory guidance classes to parents through public schools.
Provide anticipatory guidance classes to parents through public schools. This is because anticipatory guidance is a type of health teaching that involves sharing information and experiences through educational activities designed to improve health knowledge, attitudes, behaviors, and skills. Anticipatory guidance helps parents to prevent or reduce health problems in their children by providing them with information on topics such as nutrition, immunization, injury prevention, and developmental milestones. Providing anticipatory guidance classes through public schools is an example of a population-based public health intervention that aims to improve the health of a large group of people who share common characteristics or risks.
D. Launch a media campaign to increase awareness about industrial pollution.
is wrong because launching a media campaign to increase awareness about industrial pollution is not a sufficient action to improve health for the local population. While increasing awareness is an important first step, it does not necessarily lead to behavior change or environmental improvement. A media campaign alone would not address the sources and effects of industrial pollution, nor would it provide solutions or resources for the rural residents to protect themselves from exposure.
E. undefined
Full Explanation
The correct answer is choice C. Provide anticipatory guidance classes to parents through public schools. This is because anticipatory guidance is a type of health teaching that involves sharing information and experiences through educational activities designed to improve health knowledge, attitudes, behaviors, and skills. Anticipatory guidance helps parents to prevent or reduce health problems in their children by providing them with information on topics such as nutrition, immunization, injury prevention, and developmental milestones. Providing anticipatory guidance classes through public schools is an example of a population-based public health intervention that aims to improve the health of a large group of people who share common characteristics or risks.
Choice A is wrong because tertiary health interventions are not the best way to improve health for the local population. Tertiary health interventions are those that focus on treating and rehabilitating people who have already developed a disease or disability. They are more costly and less effective than primary or secondary health interventions, which aim to prevent or detect diseases early.
Encouraging rural residents to focus health spending on tertiary health interventions would not address the underlying causes of poor health in the community.
Choice B is wrong because having a nurse from outside the community provide health lectures at the county hospital is not a culturally appropriate or accessible way to deliver health education. A nurse from outside the community may not understand the needs, values, beliefs, and practices of the rural residents, and may not be able to establish trust and rapport with them. Moreover, the county hospital may not be a convenient or comfortable location for many rural residents to attend health lectures, especially if they have transportation, financial, or time barriers.
A better approach would be to involve local community members and leaders in planning and delivering health education programs that are tailored to the rural context and culture.
Choice D is wrong because launching a media campaign to increase awareness about industrial pollution is not a sufficient action to improve health for the local population. While increasing awareness is an important first step, it does not necessarily lead to behavior change or environmental improvement.
A media campaign alone would not address the sources and effects of industrial pollution, nor would it provide solutions or resources for the rural residents to protect themselves from exposure.
A more comprehensive action would be to collaborate with other stakeholders, such as environmental agencies, industry representatives, and community groups, to develop and implement strategies for reducing and monitoring industrial pollution and its impact
A nurse is caring for a client who is experiencing a panic attack.
Which of the following actions should the nurse take?
A. Administer a dose of atomoxetine to decrease anxiety.
A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADHD). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
B. Encourage the client to watch television.
because encouraging the client to watch television is not a therapeutic intervention for a panic attack. Watching television can increase the stimuli in the client’s environment, which can worsen the anxiety.
C. Teach the client how to meditate.
wrong because teaching the client how to meditate is not appropriate during a panic attack. Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis.
D. Sit with the client to provide a sense of security.
E. undefined
Sit with the client to provide a sense of security. A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus. The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.
Full Explanation
The correct answer is choice D. Sit with the client to provide a sense of security.
A client who is experiencing a panic attack has a very high level of anxiety and a diminished ability to focus.
The nurse should stay with the client and remain calm and reassuring during the panic attack. This can help the client feel safe and supported, and reduce the intensity of the anxiety.
Choice A is wrong because atomoxetine is not an anti-anxiety medication, but a selective norepinephrine reuptake inhibitor (SNRI) used to treat attention deficit hyperactivity disorder (ADHD). It has no effect on reducing anxiety and can cause side effects such as insomnia, nausea, and increased blood pressure.
Choice B is wrong because encouraging the client to watch television is not a therapeutic intervention for a panic attack.
Watching television can increase the stimuli in the client’s environment, which can worsen the anxiety.
The nurse should maintain an environment with low stimulation for the client experiencing a panic attack. Dim lighting, few people, and minimal distractions can assist the nurse to decrease the client’s level of anxiety.
Choice C is wrong because teaching the client how to meditate is not appropriate during a panic attack.
Meditation is a relaxation technique that can be helpful for preventing or reducing anxiety, but it requires concentration and focus, which are impaired in a panic attack. The nurse should teach the client how to meditate when the client is calm and receptive, not when the client is in crisis.