Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A young client diagnosed with major depressive disorder recently had their engagement broken off by their fiancé, who claimed the client was too fat and ugly.
During a one-on-one interaction with the nurse, the client says, “My fiancé is really wonderful and is not to blame for calling off the engagement.
I look awful and I’m not much good for anything.”. What is the most appropriate response by the nurse?
A. “Tell me how you felt when your fiancé broke up with you.”.
The nurse’s response, “Tell me how you felt when your fiancé broke up with you,” is the most therapeutic because it encourages the client to express feelings. This is a crucial step in the healing process. The nurse is using active listening skills and showing empathy, which can help build a therapeutic relationship with the client. It’s important for the nurse to provide a safe and nonjudgmental environment for the client to express feelings of sadness, anger, or guilt related to the breakup.
B. “Maybe the breakup was for the best.”.
The response, “Maybe the breakup was for the best,” is not therapeutic because it minimizes the client’s feelings and experiences. It’s not the nurse’s place to make judgments or assumptions about the situation. The nurse should focus on the client’s feelings and provide support.
C. “Do you think you are better off without your fiancé?”
The response, “Do you think you are better off without your fiancé?” could be seen as leading or suggestive. It’s important for the nurse to remain neutral and not impose personal beliefs or opinions on the client.
D. “How could your fiancé be wonderful after saying those things to you?”
The response, “How could your fiancé be wonderful after saying those things to you?” could be seen as confrontational and judgmental. It’s not the nurse’s role to judge the client’s relationships or experiences. The nurse should provide a supportive and understanding environment for the client to express feelings.
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
The nurse’s response, “Tell me how you felt when your fiancé broke up with you,” is the most therapeutic because it encourages the client to express feelings. This is a crucial step in the healing process. The nurse is using active listening skills and showing empathy, which can help build a therapeutic relationship with the client. It’s important for the nurse to provide a safe and nonjudgmental environment for the client to express feelings of sadness, anger, or guilt related to the breakup.
Choice B rationale
The response, “Maybe the breakup was for the best,” is not therapeutic because it minimizes the client’s feelings and experiences. It’s not the nurse’s place to make judgments or assumptions about the situation. The nurse should focus on the client’s feelings and provide support.
Choice C rationale
The response, “Do you think you are better off without your fiancé?” could be seen as leading or suggestive. It’s important for the nurse to remain neutral and not impose personal beliefs or opinions on the client.
Choice D rationale
The response, “How could your fiancé be wonderful after saying those things to you?” could be seen as confrontational and judgmental. It’s not the nurse’s role to judge the client’s relationships or experiences. The nurse should provide a supportive and understanding environment for the client to express feelings.
Similar Questions
A patient admitted to the medical-surgical unit was recently weaned from a mechanical ventilator and an IV infusion of lorazepam.
The patient has been alert and oriented for 24 hours but is now experiencing confusion.
The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the patient’s sense of place and time, difficulty focusing, short-term memory loss, and increased lethargy.
What condition does the practical nurse suspect in this patient?
A. Psychosis.
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
B. Dementia.
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
C. Amnesia.
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.
D. Delirium.
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Full Explanation
Choice D rationale
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Choice A rationale
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
Choice B rationale
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
Choice C rationale
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.
A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet.
The patient awakened and hit the UAP in the face.
Which statement best explains the patient’s action?
A. The patient interpreted the UAP’s behavior as potentially harmful.
The patient likely interpreted the UAP’s behavior as potentially harmful. This is a common reaction in confused older adults, especially when they are awakened unexpectedly. The patient may not have fully understood the situation and reacted out of fear or confusion.
B. Older adult patients often demonstrate exaggerations of behaviors used earlier in life.
While it’s true that older adults can sometimes demonstrate exaggerations of behaviors used earlier in life, there’s no information in the scenario to suggest this is the case.
C. The patient learned violent behavior by watching other patients act out.
There’s no evidence to suggest that the patient learned violent behavior by watching other patients act out. It’s more likely that the patient reacted out of fear or confusion.
D. Crowding in skilled nursing facilities increases an individual’s tendency toward violence.
While crowding can increase stress and agitation in some individuals, there’s no information in the scenario to suggest that this is a factor in the patient’s behavior.
Full Explanation
Choice A rationale
The patient likely interpreted the UAP’s behavior as potentially harmful. This is a common reaction in confused older adults, especially when they are awakened unexpectedly. The patient may not have fully understood the situation and reacted out of fear or confusion.
Choice B rationale
While it’s true that older adults can sometimes demonstrate exaggerations of behaviors used earlier in life, there’s no information in the scenario to suggest this is the case.
Choice C rationale
There’s no evidence to suggest that the patient learned violent behavior by watching other patients act out. It’s more likely that the patient reacted out of fear or confusion.
Choice D rationale
While crowding can increase stress and agitation in some individuals, there’s no information in the scenario to suggest that this is a factor in the patient’s behavior.
A 60-year-old individual strays from a football game during halftime and is discovered 48 hours later, sleeping on a park bench 100 miles away.
The individual is brought to the emergency department by the police.
The individual can state their name and address but has no memory of the past 2 days. What is the priority nursing action?
A. Monitor mental status.
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
B. Encourage the individual to recall recent events.
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
C. Assess vital signs.
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
D. Contact family members.
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.
Full Explanation
Choice A rationale
Monitoring mental status is important, but it is not the priority nursing action in this situation. The individual has been found after being missing for 48 hours and the immediate concern should be their physical well-being.
Choice B rationale
Encouraging the individual to recall recent events may be part of the assessment process, but it is not the priority nursing action. The individual’s physical health could be at risk after being outside for an extended period, and this should be addressed first.
Choice C rationale
Assessing vital signs is the priority nursing action. The individual has been found after being missing for 48 hours, potentially exposed to harsh weather conditions and without access to food or water. It is crucial to assess their physical state as they may be dehydrated, hypothermic, or have other immediate health concerns.
Choice D rationale
Contacting family members is important for providing information and support, but it is not the priority nursing action. The first concern should be to assess and stabilize the individual’s physical condition.