Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?.
A. Encourage the client to visit with the sibling.
A rationale: It’s not appropriate to pressure the client into seeing visitors.
B. Tell the sibling the client does not want visitors.
B rationale: It’s important to respect the client’s wishes and communicate them to the sibling.
C. Arrange for the sibling to visit the client in the dayroom.
C rationale: This could potentially cause distress for the client.
D. Refer the sibling to the client's provider.
D rationale: While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
It’s not appropriate to pressure the client into seeing visitors.
Choice B rationale:
It’s important to respect the client’s wishes and communicate them to the sibling.
Choice C rationale:
This could potentially cause distress for the client.
Choice D rationale:
While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
Similar Questions
A nurse is collecting data from an adult client in an outpatient mental health clinic.
The nurse should identify which of the following events as a potential cause of a maturational crisis?.
A. Motor-vehicle crash.
A rationale: A motor-vehicle crash is an adventitious crisis, not a maturational one.
B. A child leaving for college.
B rationale: A child leaving for college is a normal developmental milestone that can cause stress.
C. Loss of job.
C rationale: Loss of a job is a situational crisis, not a maturational one.
D. Divorce.
D rationale: Divorce is a situational crisis, not a maturational one.
Full Explanation
Choice A rationale:
A motor-vehicle crash is an adventitious crisis, not a maturational one.
Choice B rationale:
A child leaving for college is a normal developmental milestone that can cause stress.
Choice C rationale:
Loss of a job is a situational crisis, not a maturational one.
Choice D rationale:
Divorce is a situational crisis, not a maturational one.
A nurse is caring for a client who has a new diagnosis of cancer.
The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?.
A. Suppression
A rationale: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.
B. Reaction formation.
B rationale: Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.
C. Splitting.
C rationale: Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.
D. Projection.
D rationale: Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.
Full Explanation
Choice A rationale:
Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.
Choice B rationale:
Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.
Choice C rationale:
Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.
Choice D rationale:
Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.
A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.
A. "Having a newborn must be stressful. Do you have other children?".
A rationale: While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
B. "Tell me about your baby. Where is she now?".
B rationale: This response is the priority as it assesses the immediate safety of the baby.
C. "Do you have a friend who could help you?".
C rationale: While support is important, the immediate safety of the baby is the priority.
D. "Have you discussed this with your partner?".
D rationale: While communication with the partner is important, the immediate safety of the baby is the priority.
Full Explanation
Choice A rationale:
While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
Choice B rationale:
This response is the priority as it assesses the immediate safety of the baby.
Choice C rationale:
While support is important, the immediate safety of the baby is the priority.
Choice D rationale:
While communication with the partner is important, the immediate safety of the baby is the priority.