Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
A. Engage the panic alarm
Engaging the panic alarm is not the first action to take when interacting with an agitated client. The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures. Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
B. Use a face shield with a mask when providing care to the client.
Using a face shield with a mask when providing care to the client is not relevant to the situation. This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation. Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
C. Tell the client, “You seem to be very upset.”
Tell the client, “You seem to be very upset.”. This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.
D. Initiate seclusion protocol.
Initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly. Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
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
Tell the client, “You seem to be very upset.”.
This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).
Similar Questions
A nurse is providing teaching to a client who has a new prescription for enoxaparin.
Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
A. Naproxen sodium.
the nurse should instruct the client to avoid taking pain relievers such as naproxen sodiumwhile on enoxaparin
B. Ibuprofen.
the nurse should instruct the client to avoid taking pain relievers such as ibuprofenwhile on enoxaparin
C. Acetaminophen.
is a pain reliever that does not affect blood clotting and can be taken safely with enoxaparin. However, the client should follow the directions on the box to make sure they do not take more than the recommended amount of acetaminophen, as it can cause liver damage in high doses.
D. Aspirin.
the nurse should instruct the client to avoid taking pain relievers such as aspirinwhile on enoxaparin
E. undefined
Full Explanation
Enoxaparin is a blood thinner that helps prevent the formation of blood clots in people who have certain medical conditions or who are undergoing certain procedures. Enoxaparin can increase the risk of bleeding, especially if taken with other medications that affect blood clotting, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin.
Therefore, the nurse should instruct the client to avoid taking pain relievers such as naproxen sodium (choice A), ibuprofen (choice B), or aspirin (choice D) while on enoxaparin. These pain relievers can make the client more likely to bleed when on enoxaparin. Acetaminophen (choice C) is a pain reliever that does not affect blood clotting and can be taken safely with enoxaparin. However, the client should follow the directions on the box to make sure they do not take more than the recommended amount of acetaminophen, as it can cause liver damage in high doses.
A nurse in a provider’s office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain.
The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
A. Hypertension.
wrong because hypertension is not a contraindication for acupuncture. However, some caution is advised when needling points that may lower blood pressure, such as LI 4, LI 11, ST 36, and SP 6.
B. Hypothyroidism.
is wrong because hypothyroidism is not a contraindication for acupuncture. In fact, some studies suggest that acupuncture may have beneficial effects on thyroid function and symptoms of hypothyroidism.
C. Obesity.
C is wrong because obesity is not a contraindication for acupuncture. Acupuncture may help with weight loss by regulating appetite, metabolism, and hormones. Some of the absolute contraindications for acupuncture include pregnancy (especially certain points that may induce labor or abortion), medical and surgical emergencies, malignant tumors, bleeding disorders, and use of a demand pacemaker. Some of the relative contraindications include drug or alcohol intoxication, lack of consent, immune deficiency, abnormal heart valves, and fear of needles. Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressure respectively. Normal ranges for thyroid-stimulating hormone (TSH) are 0.4 to 4.0 mIU/L. Normal ranges for body mass index (BMI) are 18.5 to 24.9 kg/m2.
D. Herpes zoster.
. Herpes zoster is a contraindication for receiving acupuncture treatment because it is an infectious skin disorder that can be transmitted by needles or contact with the affected area. Acupuncture should not be performed on areas of skin that are inflamed, ulcerated, or have sensory deficit.
Full Explanation
Answer and explanation.
The correct answer is choice D. Herpes zoster is a contraindication for receiving acupuncture treatment because it is an infectious skin disorder that can be transmitted by needles or contact with the affected area. Acupuncture should not be performed on areas of skin that are inflamed, ulcerated, or have sensory deficit.
Choice A is wrong because hypertension is not a contraindication for acupuncture. However, some caution is advised when needling points that may lower blood pressure, such as LI 4, LI 11, ST 36, and SP 6.
Choice B is wrong because hypothyroidism is not a contraindication for acupuncture. In fact, some studies suggest that acupuncture may have beneficial effects on thyroid function and symptoms of hypothyroidism.
Choice C is wrong because obesity is not a contraindication for acupuncture.
Acupuncture may help with weight loss by regulating appetite, metabolism, and hormones.
Some of the absolute contraindications for acupuncture include pregnancy (especially certain points that may induce labor or abortion), medical and surgical emergencies, malignant tumors, bleeding disorders, and use of a demand pacemaker. Some of the relative contraindications include drug or alcohol intoxication, lack of consent, immune deficiency, abnormal heart valves, and fear of needles.
Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressure respectively.
Normal ranges for thyroid-stimulating hormone (TSH) are 0.4 to 4.0 mIU/L.
Normal ranges for body mass index (BMI) are 18.5 to 24.9 kg/m2.
A charge nurse is teaching a newly licensed nurse about the facility’s computerized documentation system.
Which of the following information should the nurse include?
A. “You will be asked to change your password once per year.”.
wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security .
B. “Documentation of sensitive material is performed by the charge nurse.”.
because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system .
C. “You will be given access to the medical records of every client in the facility.”.
because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know .
D. “Information Technology will install a firewall to secure client information.”.
The nurse should include that information technology will install a firewall to secure client information.
Full Explanation
The correct answer is choice D. The nurse should include that information technology will install a firewall to secure client information.
A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records .
Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security .
Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system .
Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know .