Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is providing teaching about home care to the family of a client who has dementia. Which of the following statements should the nurse make?
A. "Disguise exit doors in his home with posters."
People with dementia may become disoriented and attempt to leave their homes. Disguising exit doors with posters or camouflage can help prevent wandering and promote safety.
B. "Weigh the client once per month."
Weighing the client once per month is not directly related to dementia care and safety.
C. "Keep the lights in his room off at night."
Keeping lights on at night can help prevent falls and confusion in people with dementia.
D. "Offer him several food choices prior to meal times."
Offering several food choices prior to meal times can be overwhelming for a person with dementia. A simpler approach may be more appropriate.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
People with dementia may become disoriented and attempt to leave their homes. Disguising exit doors with posters or camouflage can help prevent wandering and promote safety.
Choice B rationale:
Weighing the client once per month is not directly related to dementia care and safety.
Choice C rationale:
Keeping lights on at night can help prevent falls and confusion in people with dementia.
Choice D rationale:
Offering several food choices prior to meal times can be overwhelming for a person with dementia. A simpler approach may be more appropriate.
Similar Questions
A nurse is caring for a client who has gambling disorder. Which of the following statements should the nurse make?
A. "Why do you think you enjoy gambling so much?"
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
B. "You should apologize to your family for your behavior."
Instructing the client to apologize to their family is judgmental and not therapeutic.
C. "Your family must be very angry with you right now."
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
D. "Tell me about your first experience with gambling."
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.
Full Explanation
Choice A rationale:
Asking why the client enjoys gambling doesn't address the underlying issues of gambling disorder.
Choice B rationale:
Instructing the client to apologize to their family is judgmental and not therapeutic.
Choice C rationale:
Assuming the family's emotions and feelings is not appropriate and may not be accurate.
Choice D rationale:
Asking about the client's first experience with gambling can help uncover triggers and patterns related to the disorder, which can be useful for treatment.
A nurse is caring for an infant who has tetralogy of Fallot. The infant is crying and is experiencing a hypercyanotic spell. Which of the following actions should the nurse take first?
A. Administer morphine subcutaneously.
Morphine subcutaneously can help reduce anxiety and stress, but supplying oxygen is the priority intervention.
B. Apply a face mask supplying 100% oxygen.
During a hypercyanotic spell ("tet spell"), the infant's oxygen levels drop, leading to cyanosis (blue skin) and distress. Administering oxygen can help improve oxygen saturation and alleviate the spell.
C. Attempt to calm and soothe the child.
Calming and soothing the child may not be sufficient to address the oxygen saturation issue during a hypercyanotic spell.
D. Place the infant in a knee-chest position.
Placing the infant in a knee-chest position can help improve blood flow, but administering oxygen should be the initial step.
Full Explanation
Choice A rationale:
Morphine subcutaneously can help reduce anxiety and stress, but supplying oxygen is the priority intervention.
Choice B rationale:
During a hypercyanotic spell ("tet spell"), the infant's oxygen levels drop, leading to cyanosis (blue skin) and distress. Administering oxygen can help improve oxygen saturation and alleviate the spell.
Choice C rationale:
Calming and soothing the child may not be sufficient to address the oxygen saturation issue during a hypercyanotic spell.
Choice D rationale:
Placing the infant in a knee-chest position can help improve blood flow, but administering oxygen should be the initial step.
A nurse is planning care for a client who has primary syphilis. Which of the following actions should the nurse take?
A. Monitor the client for hearing loss.
Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.
B. Use contact precautions when caring for the client.
Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.
C. Administer an antiviral medication to the client.
Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.
D. Report the infection to the public health department.
Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.
Full Explanation
Choice A rationale:
Monitoring for hearing loss is not a specific action for primary syphilis. Hearing loss can occur in later stages of syphilis.
Choice B rationale:
Contact precautions are not typically required for primary syphilis, as it is primarily transmitted through sexual contact.
Choice C rationale:
Antiviral medications are not used to treat syphilis. Antibiotics are the primary treatment.
Choice D rationale:
Syphilis is a sexually transmitted infection that is required to be reported to the public health department for tracking and control.