Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?
A. Allow the client to pace alone until physically tired.
This can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.
B. Walk with the client at a gradually slowing pace.
The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.
C. Ask a small group of other clients to walk with the client.
This may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.
D. Calmly instruct the client to stop pacing and sit in the dayroom.
This can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.
choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.
choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.
choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.
Similar Questions
A nurse is collecting data from a client who is admitted to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
A. "It's okay to feel afraid. Let's talk about what you are afraid of."
The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.
B. "Your doctor is a great surgeon. You will be fine."
"Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.
C. "Don't worry. The important thing is you have now quit smoking."
"Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.
D. "I understand your fears. I was a smoker also."
"I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.
Full Explanation
The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.
Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.
Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.
Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.
A nurse is reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder. Which of the following client statements indicates an understanding of the teaching?
A. "Disulfiram will prevent my cravings for alcohol."
"Disulfiram will prevent my cravings for alcohol," is incorrect because disulfiram works by creating a very unpleasant reaction when the client drinks alcohol and is not a medication for preventing cravings.
B. "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage."
"It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage," is incorrect because Vitamin C is not indicated for liver disease related to alcohol use disorder and is not effective in preventing it.
C. "Withdrawal symptoms should last about 5 to 7 days once they begin."
"Withdrawal symptoms should last about 5 to 7 days once they begin," is incorrect because withdrawal symptoms can last for several days or even weeks, depending on the severity of the alcohol use disorder.
D. "I should expect hand tremors to start less than 24 hours after I stop drinking."
The client should expect hand tremors to start less than 24 hours after they stop drinking when reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder.
Full Explanation
The client should expect hand tremors to start less than 24 hours after they stop drinking when reinforcing teaching about alcohol withdrawal with a client who has a history of alcohol use disorder.
Choice A, "Disulfiram will prevent my cravings for alcohol," is incorrect because disulfiram works by creating a very unpleasant reaction when the client drinks alcohol and is not a medication for preventing cravings.
Choice B, "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage," is incorrect because Vitamin C is not indicated for liver disease related to alcohol use disorder and is not effective in preventing it.
Choice C, "Withdrawal symptoms should last about 5 to 7 days once they begin," is incorrect because withdrawal symptoms can last for several days or even weeks, depending on the severity of the alcohol use disorder.
A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
A. Identify support groups in the community for long-term treatment.
Referring the client to a mental health care provider for evaluation and treatment.
B. Assist the client to identify negative effects of chemical dependency.
This may be necessary but does not address the priority concern of suicidal risk.
C. Determine the presence and degree of suicidal risk.
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment
D. Refer client to mental health care provider for evaluation and treatment.
This is animportant intervention but is not the priority at this time. Assisting the client to identify the negative effects of chemical dependency
Full Explanation
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.
choice A and referring the client to a mental health care provider for evaluation and treatment.
choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.
choice B may be necessary but does not address the priority concern of suicidal risk.