Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?
A. The client is taking numerous deep, measured breaths
This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
B. The client is calmly telling their partner that "the staff here is so controlling
This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
C. The client is sitting with their head in their hands and appears to be crying
This is not an indication of potential violence, but rather a sign of sadness or distress.
D. The client is pacing around the chair in which their partner is sitting
This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
This question is an excerpt from Nurse Dive's nursing test bank - RN Comprehensive Online Practice 2019 B with NGN Proctored Exam. Take the full exam now
Full Explanation
The client is pacing around the chair in which their partner is sitting.
Rationale:
- A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
- B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
- C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
- D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
Similar Questions
A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?
A. Assess fluid intake every 24 hr.
Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
B. Ambulate three times a day.
Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
C. Assist with deep breathing and coughing.
Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
D. Monitor the incision site for findings of infection.
Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
Full Explanation
- A. Assessing fluid intake every 24 hr is important for a postoperative client, but it is not the priority action. The nurse should monitor fluid intake and output more frequently, such as every 8 hr or every shift, to detect any imbalances or complications.
- B. Ambulating three times a day is beneficial for a postoperative client, but it is not the priority action. The nurse should encourage early and frequent ambulation to promote circulation, prevent thromboembolism, and enhance bowel function, but only after ensuring that the client is stable and has adequate pain control.
- C. Assisting with deep breathing and coughing is the priority action for a postoperative client who had abdominal surgery. The nurse should help the client perform these exercises every 1 to 2 hr to prevent atelectasis, pneumonia, and respiratory failure, which are common and serious complications after abdominal surgery.
- D. Monitoring the incision site for findings of infection is important for a postoperative client, but it is not the priority action. The nurse should inspect the wound for signs of infection, such as redness, swelling, warmth, drainage, or odor, but this can be done during routine dressing changes or as needed.
A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?
A. "Perhaps you think the ECT is dangerous, but I've seen it have good results."
This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
B. "You have the right to change your mind about this procedure at any time."
This response respects the client's autonomy and informs them of their rights.
C. "Everyone gets a little nervous about this procedure as the time for it approaches."
This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you."
Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.
Full Explanation
You have the right to change your mind about this procedure at any time.
Rationale:
- A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." This response is dismissive of the client's concerns and implies that the nurse knows better than the client.
- B. "You have the right to change your mind about this procedure at any time." This response respects the client's autonomy and informs them of their rights.
- C. "Everyone gets a little nervous about this procedure as the time for it approaches." This response minimizes the client's feelings and assumes that they are experiencing normal anxiety.
- D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you." This response shifts the responsibility to the doctor and does not address the client's fears.
A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?
A. Check the client's blood type and crossmatch it against the provider's orders
This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B. Ask the client to state their blood type prior to beginning blood administration
This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C. Compare information on the blood product to the informed consent form
This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D. Verify the client and blood product information with another licensed nurse
This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.
Full Explanation
Verify the client and blood product information with another licensed nurse.
Rationale:
- A - This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
- B - This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
- C - This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
- D - This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.