Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is speaking with a client who is experiencing a situational crisis following the sudden death of his partner. Which of the following questions should the nurse ask the client first?
A. "Who do you talk to when you feel overwhelmed?"
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
B. "Are you thinking about harming yourself?"
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
C. "Can we talk about how your partner's death has affected you?"
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
D. "What do you usually do to calm your thoughts?"
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
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:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
Similar Questions
A nurse is providing teaching to the parents of a school-age child who has a new prescription for somatropin to treat growth hormone deficiency. Which of the following statements should the nurse make?
A. "This medication might cause hypoglycemia."
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
B. "Place this medication under your child's tongue."
Somatropin is usually administered via injection, not under the tongue.
C. "This medication might cause ringing in your child's ears,"
Ringing in the ears is not a common side effect of somatropin.
D. "Measure your child's height monthly while taking this medication."
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
Full Explanation
Choice A rationale:
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
Choice B rationale:
Somatropin is usually administered via injection, not under the tongue.
Choice C rationale:
Ringing in the ears is not a common side effect of somatropin.
Choice D rationale:
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
A nurse is assessing a client who has a new diagnosis of major depressive disorder.
Which of the following client statements should the nurse expect?
A. "I feel like my mood has been all over the place."
Rapid mood swings are not a defining characteristic of major depressive disorder.
B. "I recently started hearing voices in my head."
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
C. “I cannot trust you enough to tell you how I feel."
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
D. "just don't feel like doing things I usually enjoy."
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
E. "just don't feel like doing things I usually enjoy."
Full Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
A nurse is creating a plan of care for a newborn who is breastfed and appears jaundiced.
Which of the following interventions should the nurse include?
A. Place the newborn under a radiant warmer.
Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.
B. Supplement breastfeeding with iron-fortified formula.
Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.
C. Determine the effectiveness of breastfeeding.
Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.
D. Administer Rho(D) immune globin to the newborn.
Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.
Full Explanation
Choice A rationale:
Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.
Choice B rationale:
Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.
Choice C rationale:
Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.
Choice D rationale:
Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.