Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on a mental health unit is admitting a client following a suicide attempt. Which of the following actions is the nurse's priority?
A. Establish a therapeutic relationship with the client.
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
B. Instruct the client on stress management techniques.
Instructing the client on stress management techniques is important, but safety comes first.
C. Have the client sign a no-suicide contract.
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
D. Maintain constant observation of the client.
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
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:
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
Choice B rationale:
Instructing the client on stress management techniques is important, but safety comes first.
Choice C rationale:
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
Choice D rationale:
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
Similar Questions
A nurse is teaching the partner of a client who has a new diagnosis of Alzheimer's disease about home care. Which of the following information should the nurse include in the teaching?
A. "Keep the television on at a low volume in the background."
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
B. "Decorate your partner's room with abstract paintings."
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
C. "Reorient your partner daily to the day and time."
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
D. "Use dim lighting in your home."
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.
Full Explanation
Choice A rationale:
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
Choice B rationale:
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
Choice C rationale:
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
Choice D rationale:
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.
A nurse is providing teaching to a client who has neutropenia about preventing foodborne illness. Which of the following instructions should the nurse include?
A. "Thaw frozen foods at room temperature before cooking."
Thawing frozen foods at room temperature can promote bacterial growth, increasing the risk of foodborne illness.
B. "Reduce your intake of calcium-containing foods."
There is no need for the client to reduce their intake of calcium-containing foods specifically to prevent foodborne illness. Calcium-containing foods are not associated with an increased risk of bacterial contamination.
C. "Cook raw fish and steak to the well-done stage."
Cooking raw fish and steak to the well-done stage is recommended to kill harmful bacteria and reduce the risk of foodborne illness, which is particularly important for individuals with neutropenia who are more susceptible to infections.
D. "Cut damaged areas from fruits and vegetables before consuming."
Cutting damaged areas from fruits and vegetables is a good practice to reduce the risk of contamination, but it does not address the risk of bacterial contamination from undercooked meat and fish.
Full Explanation
Choice A rationale:
Thawing frozen foods at room temperature can promote bacterial growth, increasing the risk of foodborne illness.
Choice B rationale:
There is no need for the client to reduce their intake of calcium-containing foods specifically to prevent foodborne illness. Calcium-containing foods are not associated with an increased risk of bacterial contamination.
Choice C rationale:
Cooking raw fish and steak to the well-done stage is recommended to kill harmful bacteria and reduce the risk of foodborne illness, which is particularly important for individuals with neutropenia who are more susceptible to infections.
Choice D rationale:
Cutting damaged areas from fruits and vegetables is a good practice to reduce the risk of contamination, but it does not address the risk of bacterial contamination from undercooked meat and fish.
A newly licensed nurse is experiencing bullying from another staff nurse. Which of the following actions should the newly licensed nurse take?
A. File a transfer request to be assigned to a different unit.
Filing a transfer request might be considered if the bullying behavior persists despite attempts to address it, but it's important for the newly licensed nurse to initially address the behavior directly.
B. Discuss the matter with the facility's quality improvement team.
Discussing the matter with the facility's quality improvement team might be necessary if the situation escalates, but addressing the behavior directly with the coworker is the initial step.
C. Introduce a no-tolerance policy for incivility at the next unit meeting.
Introducing a no-tolerance policy for incivility is a good idea, but addressing the specific behavior with the coworker is important in the moment.
D. Calmly address the coworker's behavior as soon as it occurs.
Calmly addressing the coworker's behavior as soon as it occurs is a proactive way to assert boundaries and address the bullying behavior directly.
Full Explanation
Choice A rationale:
Filing a transfer request might be considered if the bullying behavior persists despite attempts to address it, but it's important for the newly licensed nurse to initially address the behavior directly.
Choice B rationale:
Discussing the matter with the facility's quality improvement team might be necessary if the situation escalates, but addressing the behavior directly with the coworker is the initial step.
Choice C rationale:
Introducing a no-tolerance policy for incivility is a good idea, but addressing the specific behavior with the coworker is important in the moment.
Choice D rationale:
Calmly addressing the coworker's behavior as soon as it occurs is a proactive way to assert boundaries and address the bullying behavior directly.