Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?
A. State expectations for the client's behavior.
By stating expectations for the client's behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation. It also helps maintain a therapeutic and safe environment for all clients on the unit.
B. Request security personnel restrain the client.
Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
C. Place the client in seclusion.
Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
D. Debrief staff members about the conflict.
Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is Choice A.
Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.
Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
Similar Questions
A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect?
A. Grandiose thinking
Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.
B. Hypersomnia
Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.
C. Blunted affect
Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.
D. Slurred speech
Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.
Full Explanation
Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.
Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.
Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.
Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.
A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "Following a blood spill. I should use a bleach solution with a ratio of 1 to 20."
According to standard precautions, a 1:10 bleach solution (1 part bleach to 10 parts water) is recommended for cleaning up blood spills.
B. "Soiled dressings should be placed in a biohazard trash receptacle."
Soiled dressings, which may contain infectious materials, should be disposed of in a biohazardous waste container to prevent the spread of infection.
C. "For a client who has Clostridium difficile. I will cleanse my hands with an alcohol-based rub."
Alcohol-based hand rubs are not effective against Clostridium difficile. Handwashing with soap and water is necessary to remove the spores.
D. "Droplet precautions require that I wear a gown and gloves when providing client care."
Droplet precautions typically require wearing a surgical mask, not a gown and gloves. Gowns and gloves are used in contact precautions.
Full Explanation
Soiled dressings, which may contain infectious materials, should be disposed of in a biohazardous waste container to prevent the spread of infection.
According to standard precautions, a 1:10 bleach solution (1 part bleach to 10 parts water) is recommended for cleaning up blood spills.
Alcohol-based hand rubs are not effective against Clostridium difficile. Handwashing with soap and water is necessary to remove the spores.
Droplet precautions typically require wearing a surgical mask, not a gown and gloves. Gowns and gloves are used in contact precautions.
A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will increase the flow rate if I feel short of breath."
Adjusting the oxygen flow rate should be done based on the healthcare provider's instructions and not solely based on subjective feelings. The client should follow the prescribed flow rate and consult their healthcare provider if experiencing increased shortness of breath.
B. "I will check my oxygen equipment at least once daily."
This statement shows that the client understands the importance of regularly checking the oxygen equipment for proper functioning and potential issues. Regular equipment checks help ensure the client's safety and effective oxygen therapy.
C. "I can use isopropyl alcohol to clean the nasal cannula when necessary."
Isopropyl alcohol is not recommended for cleaning the nasal cannula as it can cause drying and irritation. The client should use mild soap and water for cleaning the nasal cannula as per the healthcare provider's instructions.
D. "I can use synthetic blankets on my bed."
Synthetic blankets can generate static electricity, which could be a fire hazard in the presence of oxygen. The client should be advised to use cotton or wool blankets, which are non-flammable and safer with oxygen therapy.
Full Explanation
This statement shows that the client understands the importance of regularly checking the oxygen equipment for proper functioning and potential issues. Regular equipment checks help ensure the client's safety and effective oxygen therapy.
Adjusting the oxygen flow rate should be done based on the healthcare provider's instructions and not solely based on subjective feelings. The client should follow the prescribed flow rate and consult their healthcare provider if experiencing increased shortness of breath.
Isopropyl alcohol is not recommended for cleaning the nasal cannula as it can cause drying and irritation. The client should use mild soap and water for cleaning the nasal cannula as per the healthcare provider's instructions.
Synthetic blankets can generate static electricity, which could be a fire hazard in the presence of oxygen. The client should be advised to use cotton or wool blankets, which are non-flammable and safer with oxygen therapy.