Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A spouse brings a client to an extremely busy emergency department due to erratic behavior and expressions of despair.
When the triage registered nurse asks if the client feels suicidal now, the client shrugs their shoulders. Based on these findings, which nursing responsibility is the practical nurse expected to be assigned?
A. Ask the client to make a verbal contract to not harm self.
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
B. Return the client to the waiting room with the spouse.
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
C. Document that the client is not currently suicidal.
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
D. Place the client in an inside hallway with one-on-one observation.
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.
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Full Explanation
Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.
Similar Questions
A client who recently went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit.
Which of the following nursing diagnoses has the highest priority?
A. Ineffective coping related to inadequate stress management.
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
B. Hopelessness related to recent divorce.
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
C. Spiritual distress related to conflicting thoughts about suicide and sin.
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
D. Risk for suicide related to highly lethal plan.
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
Full Explanation
Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
Choice B rationale
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
Choice D rationale
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.
What are the goals of therapeutic communication?
A. Foster a social relationship.
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. Therapeutic communication in nursing is patient-centered and should involve a holistic approach, including aspects of psychological, physiological, spiritual, and environmental care of the patient.
B. Focus on the attitude of the client.
Focusing on the attitude of the client is not the main goal of therapeutic communication. While understanding the client’s attitude can provide valuable insights into their feelings and perspectives, the primary goal is to build a rapport and focus on the client.
C. Focus on the client and build a rapport.
Focusing on the client and building a rapport is the main goal of therapeutic communication in nursing. It helps nurses build trust with patients while also helping establish collaborative efforts to promote efficient and effective patient care, improving patient outcomes.
D. Focus on the staff member and build rapport.
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The focus should be on the client, their needs, and their experiences.
Full Explanation
Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. Therapeutic communication in nursing is patient-centered and should involve a holistic approach, including aspects of psychological, physiological, spiritual, and environmental care of the patient.
Choice B rationale
Focusing on the attitude of the client is not the main goal of therapeutic communication. While understanding the client’s attitude can provide valuable insights into their feelings and perspectives, the primary goal is to build a rapport and focus on the client.
Choice C rationale
Focusing on the client and building a rapport is the main goal of therapeutic communication in nursing. It helps nurses build trust with patients while also helping establish collaborative efforts to promote efficient and effective patient care, improving patient outcomes.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The focus should be on the client, their needs, and their experiences.
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?
A. Increasing feelings of anger.
Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including: Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives. Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust. Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma. Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt. Anger can manifest in various ways, including: Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors. Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger. Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.
B. Sleeping 12 hours or more each day.
Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.
C. Increasing sense of attachment to others.
PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.
D. Constant need to talk about the event.
While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.
Full Explanation
Choice A rationale:
Anger is a common and expected response to trauma, including sexual assault. It can stem from various sources, including:
Feelings of violation and powerlessness: Survivors may feel intense anger towards the perpetrator for taking control of their bodies and lives.
Betrayal: If the assault was committed by someone they knew or trusted, survivors may feel intense anger towards that person for breaking their trust.
Frustration and injustice: Survivors may feel angry at the injustice of the situation, the lack of control they had, and the ongoing impact of the trauma.
Difficulty processing other emotions: Anger can sometimes mask other emotions that are difficult to deal with, such as fear, sadness, or guilt.
Anger can manifest in various ways, including:
Irritability and outbursts: Survivors may have a short temper, snap at others easily, or have difficulty controlling their anger. Aggression: In some cases, anger can lead to physical or verbal aggression towards others or self-harming behaviors.
Withdrawal and isolation: Some survivors may withdraw from social interactions and relationships to avoid potential triggers for their anger.
Substance abuse: Some survivors may turn to alcohol or drugs to numb their feelings or cope with their anger.
Choice B rationale:
Sleeping 12 hours or more each day can be a symptom of PTSD, but it is not a specific indicator of anger. It can also be a sign of depression, anxiety, or hypersomnia, a sleep disorder characterized by excessive daytime sleepiness.
Choice C rationale:
PTSD can sometimes lead to an increased sense of detachment from others, rather than attachment. Survivors may feel emotionally numb, have difficulty trusting others, or withdraw from relationships.
Choice D rationale:
While some survivors of sexual assault may feel a need to talk about the event, it is not a universal symptom of PTSD. Some survivors may avoid talking about the event altogether due to the distress it causes.