Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?
A. "I can designate my partner as my health care surrogate."
Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
B. "I am only 40 years old, so I don't need to worry about this yet."
Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
C. “I will need a lawyer's help to draw up the documents."
A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.
D. “I understand that my family can alter my advance directives if I become incapacitated."
The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
"I can designate my partner as my health care surrogate."
- A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.
- B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.
- C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults. - D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.
Similar Questions
A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will administer aspirin to my child to treat pain or fever."
Aspirin can trigger asthma attacks in some children and should be avoided.
B. "I will record an average of three readings from my child's peak expiratory flow meter."
The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.
C. I will place carpet in my child's bedroom to control allergens."
Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.
D. "I will make sure my child receives a yearly influenza immunization."
Influenza immunization can prevent serious complications from respiratory infections in children with asthma.
Full Explanation
A: Incorrect. Aspirin can trigger asthma attacks in some children and should be avoided.
B: Incorrect. The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.
C: Incorrect. Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.
D: Correct. Influenza immunization can prevent serious complications from respiratory infections in children with asthma.
A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?
A. "I would like to talk to you about the unit policies regarding break time."
A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
B. "If you continue to take a long lunch break, I will have to report this to the nurse manager."
B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
C. "Have you thought about how your extended lunch breaks affect the other members of our team?"
C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
D. "Did you inform the other members of your team about when you left and returned from break?"
D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.
Full Explanation
- A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
- B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
- C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
- D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.
A nurse is assessing a client who has major depressive disorder and is taking amitriptyline.
Which of the following findings should the nurse identify as an adverse effect of the medication?
A. Diarrhea
Diarrhea is not an adverse effect of amitriptyline, which is a tricyclic antidepressant (TCA). Diarrhea may be caused by other factors, such as infection, food intolerance, or stress. Therefore, this choice is incorrect.
B. Frequent urination
Frequent urination is not an adverse effect of amitriptyline either. Frequent urination may be a sign of diabetes, urinary tract infection, or other conditions that affect the kidneys or bladder. Therefore, this choice is also incorrect.
C. Excessive salivation
Excessive salivation is not an adverse effect of amitriptyline as well. Excessive salivation may be due to increased production of saliva, difficulty swallowing, or mouth irritation. Therefore, this choice is incorrect too.
D. Blurred vision
Blurred vision is an adverse effect of amitriptyline and other TCAs. Amitriptyline can cause anticholinergic effects, such as dry mouth, constipation, urinary retention, and blurred vision. These effects are more pronounced in older adults and can impair their daily functioning and quality of life. Therefore, this choice is correct and the nurse should identify it as an adverse effect of the medication.
Full Explanation
- A. Diarrhea is not an adverse effect of amitriptyline, which is a tricyclic antidepressant (TCA). Diarrhea may be caused by other factors, such as infection, food intolerance, or stress. Therefore, this choice is incorrect.
- B. Frequent urination is not an adverse effect of amitriptyline either. Frequent urination may be a sign of diabetes, urinary tract infection, or other conditions that affect the kidneys or bladder. Therefore, this choice is also incorrect.
- C. Excessive salivation is not an adverse effect of amitriptyline as well. Excessive salivation may be due to increased production of saliva, difficulty swallowing, or mouth irritation. Therefore, this choice is incorrect too.
- D. Blurred vision is an adverse effect of amitriptyline and other TCAs. Amitriptyline can cause anticholinergic effects, such as dry mouth, constipation, urinary retention, and blurred vision. These effects are more pronounced in older adults and can impair their daily functioning and quality of life. Therefore, this choice is correct and the nurse should identify it as an adverse effect of the medication.