Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient is pacing the hall near the nurse’s station, swearing loudly. What would be an appropriate initial intervention for the nurse?
A. Please be quiet and sit down in this chair immediately.
Telling the patient to be quiet and sit down immediately may seem like a quick solution, but it is not the most therapeutic response. This approach may come across as dismissive and authoritarian, which could escalate the patient’s agitation.
B. I’d like to talk with you about how you’re feeling right now.
This is the most appropriate initial intervention. By expressing a desire to understand the patient’s feelings, the nurse opens up a line of communication and shows empathy. This can help de-escalate the situation and make the patient feel heard and understood.
C. You must go to your room and try to control yourself.
Telling the patient to go to their room and control themselves can come across as dismissive and invalidating. It does not address the patient’s feelings or concerns and may escalate the situation.
D. What is going on?
Asking “What is going on?” is a good way to encourage the patient to express their feelings, but it may not be as effective as Choice B. The phrasing in Choice B is more direct and shows more empathy and concern for the patient’s emotional state.
This question is an excerpt from Nurse Dive's nursing test bank - Lpn Ati Mental Health Psychosocial Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale
Telling the patient to be quiet and sit down immediately may seem like a quick solution, but it is not the most therapeutic response. This approach may come across as dismissive and authoritarian, which could escalate the patient’s agitation.
Choice B rationale
This is the most appropriate initial intervention. By expressing a desire to understand the patient’s feelings, the nurse opens up a line of communication and shows empathy. This can help de-escalate the situation and make the patient feel heard and understood.
Choice C rationale
Telling the patient to go to their room and control themselves can come across as dismissive and invalidating. It does not address the patient’s feelings or concerns and may escalate the situation.
Choice D rationale
Asking “What is going on?” is a good way to encourage the patient to express their feelings, but it may not be as effective as Choice B. The phrasing in Choice B is more direct and shows more empathy and concern for the patient’s emotional state.
Similar Questions
During the mental status examination, the nurse observes that the client rapidly shifts from one idea to another related thought. Which disordered thinking process is the client displaying?
A. Ideas of reference.
Ideas of reference involve the belief that casual events, people’s remarks, or elements in the environment have a particular and unusual meaning specifically for oneself. This is not what is being described in the question.
B. Perseveration.
Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus. It is usually caused by a brain injury or other organic disorder. This is not what is being described in the question.
C. Flight of ideas.
Flight of ideas is a symptom of a thought disorder that causes a rapid shift from one idea to another. This symptom is often seen in conditions like bipolar disorder, particularly during manic episodes. This matches the description given in the question.
D. Confabulation.
Confabulation is a memory disturbance in which a person confuses imagined scenarios with actual memories, with no intent to deceive. This is not what is being described in the question.
Full Explanation
Choice A rationale
Ideas of reference involve the belief that casual events, people’s remarks, or elements in the environment have a particular and unusual meaning specifically for oneself. This is not what is being described in the question.
Choice B rationale
Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus. It is usually caused by a brain injury or other organic disorder. This is not what is being described in the question.
Choice C rationale
Flight of ideas is a symptom of a thought disorder that causes a rapid shift from one idea to another. This symptom is often seen in conditions like bipolar disorder, particularly during manic episodes. This matches the description given in the question.
Choice D rationale
Confabulation is a memory disturbance in which a person confuses imagined scenarios with actual memories, with no intent to deceive. This is not what is being described in the question.
In communicating with the psychiatric patient, which nurse responses could obstruct effective communication with a client? (Select all that apply)
A. Tell me more about what you are feeling.
This response encourages the patient to express their feelings and promotes open communication. It is a therapeutic communication technique.
B. It must be difficult for you to feel that way.
This response shows empathy and validates the patient’s feelings. It is a therapeutic communication technique.
C. You should talk to your husband and not keep things inside.
This response could obstruct effective communication as it tells the patient what they should do. It does not encourage the patient to express their feelings or promote open communication.
D. Everything will turn out fine.
This response could obstruct effective communication as it offers false reassurance. It does not acknowledge the patient’s feelings or concerns.
Full Explanation
Choice A rationale
This response encourages the patient to express their feelings and promotes open communication. It is a therapeutic communication technique.
Choice B rationale
This response shows empathy and validates the patient’s feelings. It is a therapeutic communication technique.
Choice C rationale
This response could obstruct effective communication as it tells the patient what they should do. It does not encourage the patient to express their feelings or promote open communication.
Choice D rationale
This response could obstruct effective communication as it offers false reassurance. It does not acknowledge the patient’s feelings or concerns.
Haldol 2mg IM stat has been ordered for the agitated client. Haldol is available in 5mg/ml. How many ml’s will you administer?
A. 0.2 ml.
B. 0.4 ml.
Step 1 is to determine the amount of medication to administer. The order is for Haldol 2mg IM stat. The available medication is Haldol 5mg/ml. To find out how many ml’s to administer, you would divide the ordered dose by the available dose. So, 2mg ÷ 5mg/ml = 0.4 ml.
C. 0.6 ml.
D. 0.8 ml.
Full Explanation
Step 1 is to determine the amount of medication to administer. The order is for Haldol 2mg IM stat. The available medication is Haldol 5mg/ml. To find out how many ml’s to administer, you would divide the ordered dose by the available dose. So, 2mg ÷ 5mg/ml = 0.4 ml.