Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A public health nurse is assessing an older adult client who lives with a family member.
The nurse identifies several bruises in various stages of healing. The client and family members explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse.
Which of the following actions should the nurse take first?
A. Investigate further to confirm the suspicion.
Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.
B. Report the findings.
The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.
C. Provide the client with a crisis hotline number.
Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being. The client might not be able to access the hotline or might be afraid to use it.
D. Discuss respite care with the client’s family.
Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage. The nurse should not assume that the family member is willing or able to provide adequate care for the client. Respite care might be an option after the abuse is reported and investigated.
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Full Explanation
The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.
Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.
Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.
The client might not be able to access the hotline or might be afraid to use it.
Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.
The nurse should not assume that the family member is willing or able to provide adequate care for the client.
Respite care might be an option after the abuse is reported and investigated.
Similar Questions
Your patient was outdoors and developed hypothermia.
You know that independent nursing interventions would include:
A. Soaking extremities in hot water.
Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension
B. Administering warmed intravenous fluids.
Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac
C. Administering hot whirlpool therapy.
Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiacdysrhythmias.
D. Replacing wet clothing with dry clothing.
Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient.
Full Explanation
Replacing wet clothing with dry clothing is an independent nursing intervention that can help prevent further heat loss and gradually warm the patient. Soaking extremities in hot water (choice A) is not recommended because it can cause vasodilation and hypotension. Administering warmed intravenous fluids (choice B) and administering hot whirlpool therapy (choice C) are not independent nursing interventions because they require a physician’s order. They are also not appropriate for mild to moderate hypothermia because they can cause rapid rewarming and cardiac dysrhythmias.
A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic.
Upon physical assessment, what signs would the provider expect to see? (Select all that apply)
A. Bradypnea.
Choice A is wrong because bradypnea is abnormally slow breathing, which is not a sign of anemia. Anemia can cause tachypnea, which is abnormally fast breathing.
B. Tachycardia.
It isa signof anaemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.
C. Nail bed pallor.
It isa signof anaemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.
D. Pallor of conjunctiva.
It isa signof anaemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.
Full Explanation
These are signs of anemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.
Anemia can cause fatigue, weakness, pale skin, cold hands and feet, dizziness, reduced immunity and shortness of breath.
Choice A is wrong because bradypnea is abnormally slow breathing, which is not a sign of anemia. Anemia can cause tachypnea, which is abnormally fast breathing.
Choice E is wrong because flushed skin is not a sign of anemia. Anemia can cause pallor, which is pale or yellowish skin.
Flushed skin can be a sign of other conditions, such as fever, infection or allergic reaction.
Normal ranges for hemoglobin levels vary depending on age and gender. For adult males, the normal range is 13.5 to 17.5 grams per deciliter (g/dL) of blood. For adult females, the normal range is 12 to 15.5 g/dL of blood.
A nurse is caring for a patient who has complaints of fatigue.
If the fatigue is caused by lifestyle choices, what should the nurse recommend for fatigue prevention? (Select all that apply)
A. Maintain a regular sleep routine.
Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.
B. Eat 3 large meals a day.
Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy.
C. Limit refined sugar, fried foods, and processed foods.
Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body. These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.
D. Take daily walks.
Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system
E. Take more coffee.
Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue. Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms
Full Explanation
Choice A is correct because maintaining a regular sleep routine can help regulate your circadian rhythm, which is your body’s natural sleep-wake cycle. This can improve the quality and quantity of your sleep and reduce daytime sleepiness.
Choice B is wrong because eating three large meals a day can cause fluctuations in your blood sugar levels, which can affect your energy levels. It is better to eat smaller, more frequent meals and snacks that contain a balance of protein and carbohydrates to keep your blood sugar stable and provide sustained energy. Choice C is correct because limiting refined sugar, fried foods and processed foods can help prevent fatigue by reducing inflammation and oxidative stress in your body.
These foods can also cause spikes and crashes in your blood sugar levels, which can make you feel tired and hungry. Instead, you should eat more anti-inflammatory foods, such as fruits, vegetables, nuts, seeds and fish.
Choice D is correct because taking daily walks can help prevent fatigue by increasing your blood circulation, oxygen delivery and endorphin production. Exercise can also improve your mood, sleep quality and immune system.
Choice E is wrong because increasing caffeine intake can have the opposite effect of preventing fatigue.
Caffeine is a stimulant that can temporarily boost your energy levels, but it can also disrupt your sleep, cause dehydration, increase anxiety and lead to withdrawal symptoms