Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on an inpatient mental health unit is caring for a client who was admitted for suicidal ideation.
Which of the following statements by the client should the nurse identify as a continuation of suicidal ideation?
A. "I'm going to continue to not drink alcohol when I get home.”.
Continuing to abstain from alcohol is a positive step towards maintaining mental health, not a sign of suicidal ideation.
B. "Walking around the hospital grounds has been helping me.”.
Finding therapeutic activities like walking around the hospital grounds is a positive coping mechanism, not a sign of suicidal ideation.
C. "I'm looking forward to seeing my grandchildren when I get out of here.”.
Looking forward to future events like seeing grandchildren is a positive sign and not indicative of suicidal ideation.
D. "I'm going to give my sister my pottery collection when I get home.”. .
Giving away possessions, like a pottery collection, can be a sign of suicidal ideation as it may indicate the client is putting their affairs in order.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Custom Nurs 120 Psychiatric Nursing Fa23 Proctored Exam 2. Take the full exam now
Full Explanation
Choice A rationale:
Continuing to abstain from alcohol is a positive step towards maintaining mental health, not a sign of suicidal ideation.
Choice B rationale:
Finding therapeutic activities like walking around the hospital grounds is a positive coping mechanism, not a sign of suicidal ideation.
Choice C rationale:
Looking forward to future events like seeing grandchildren is a positive sign and not indicative of suicidal ideation.
Choice D rationale:
Giving away possessions, like a pottery collection, can be a sign of suicidal ideation as it may indicate the client is putting their affairs in order.
Similar Questions
A nurse is teaching a client who has bipolar disorder about lithium.
Which of the following statements should the nurse include in the teaching?.
A. "Take the medication on an empty stomach.”.
Taking lithium on an empty stomach is not necessary. Lithium can be taken with or without food.
B. "You might produce extra saliva while taking this medication.”.
Excessive salivation is not a common side effect of lithium.
C. "Notify your provider if you experience vomiting or diarrhea.”.
Vomiting or diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium. Therefore, it’s important to notify your provider if you experience these symptoms.
D. "Decrease your fluid intake to 1 liter per day.”.
Decreasing fluid intake can lead to dehydration and increase the risk of lithium toxicity. It’s recommended to maintain a normal fluid intake while taking lithium.
Full Explanation
Choice A rationale:
Taking lithium on an empty stomach is not necessary. Lithium can be taken with or without food.
Choice B rationale:
Excessive salivation is not a common side effect of lithium.
Choice C rationale:
Vomiting or diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium. Therefore, it’s important to notify your provider if you experience these symptoms.
Choice D rationale:
Decreasing fluid intake can lead to dehydration and increase the risk of lithium toxicity. It’s recommended to maintain a normal fluid intake while taking lithium.
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?
A. Drinking green tea.
Drinking green tea does not directly cause lithium toxicity.
B. Exercising moderately.
Moderate exercise does not directly cause lithium toxicity.
C. Increasing sodium intake.
Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.
D. Experiencing diarrhea.
Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.
Full Explanation
Choice A rationale:
Drinking green tea does not directly cause lithium toxicity.
Choice B rationale:
Moderate exercise does not directly cause lithium toxicity.
Choice C rationale:
Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.
Choice D rationale:
Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.
A nurse is discussing schizophrenia spectrum disorders with a client.
The client states, "My friend says that before I started hearing voices, I stopped hanging out with them.
Why is that?" Which of the following responses should the nurse make?
A. "That is very interesting.We are not sure why people start to isolate themselves.”.
While it’s interesting to consider why people isolate themselves, this statement does not provide a clear explanation for the behavior.
B. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize.”.
Being an introvert or extrovert doesn’t necessarily correlate with the onset of schizophrenia symptoms.
C. "Before symptoms of schizophrenia begin, people often isolate themselves.This is an early warning.”.
Before symptoms of schizophrenia begin, people often isolate themselves. This is known as the prodromal phase of schizophrenia.
D. "Were you avoiding your friend so that you could hear the voices more clearly?". .
Avoiding friends to hear voices more clearly is not a typical behavior associated with the onset of schizophrenia.
Full Explanation
Choice A rationale:
While it’s interesting to consider why people isolate themselves, this statement does not provide a clear explanation for the behavior.
Choice B rationale:
Being an introvert or extrovert doesn’t necessarily correlate with the onset of schizophrenia symptoms.
Choice C rationale:
Before symptoms of schizophrenia begin, people often isolate themselves. This is known as the prodromal phase of schizophrenia.
Choice D rationale:
Avoiding friends to hear voices more clearly is not a typical behavior associated with the onset of schizophrenia.