Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The decision to intervene as a patient advocate is clearly identified by the American Nurses Association's (ANA) code of ethics in which situation?
A. A suspicion that a staff member is unfit to provide client care
This situation reflects the responsibility of a nurse to advocate for patients' safety by intervening if they suspect a staff member is unfit to provide proper care.
B. Working with a client to identify triggers for aggressive behavior
Working with a client to identify triggers for aggressive behavior is more related to the therapeutic process than the specific role of patient advocacy.
C. A client's need for assistance while ambulating post-surgery
A client's need for assistance while ambulating post-surgery is part of standard nursing care but does not directly involve patient advocacy.
D. Providing emotional support to a client experiencing a loss of a parent
Providing emotional support to a client experiencing a loss is part of nursing care but does not specifically address the nurse's role as a patient advocate.
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Full Explanation
A. This situation reflects the responsibility of a nurse to advocate for patients' safety by intervening if they suspect a staff member is unfit to provide proper care.
B. Working with a client to identify triggers for aggressive behavior is more related to the therapeutic process than the specific role of patient advocacy.
C. A client's need for assistance while ambulating post-surgery is part of standard nursing care but does not directly involve patient advocacy.
D. Providing emotional support to a client experiencing a loss is part of nursing care but does not specifically address the nurse's role as a patient advocate.
Similar Questions
A nurse is planning a unit orientation for a newly admitted client who has severe depression. Which of the following should be the nurse's approach?
A. Sit with the client and offer simple, direct information.
For a client with severe depression, a calm and direct approach is beneficial. Sitting with the client and offering simple, clear information can help establish trust and rapport.
B. Have the client attend group therapy immediately.
Attending group therapy immediately might overwhelm the client, especially if they are newly admitted and experiencing severe depression.
C. Take the client on a tour of the unit and introduce him to all the staff members on duty.
Taking the client on a tour and introducing all staff members might be overwhelming or excessive for someone with severe depression.
D. Explain the unit policies to the client and answer any questions he might have.
While explaining unit policies is important, a direct informational approach might be more effective initially given the severity of the client's condition.
Full Explanation
A. For a client with severe depression, a calm and direct approach is beneficial. Sitting with the client and offering simple, clear information can help establish trust and rapport.
B. Attending group therapy immediately might overwhelm the client, especially if they are newly admitted and experiencing severe depression.
C. Taking the client on a tour and introducing all staff members might be overwhelming or excessive for someone with severe depression.
D. While explaining unit policies is important, a direct informational approach might be more effective initially given the severity of the client's condition.
A nurse answers a suicide crisis line. A caller says, "I live alone in a home several miles from my nearest neighbors. I have been considering suicide for 2 months. I have had several drinks and now my gun is loaded. I'm going to shoot myself in the heart." How would the nurse assess the lethality of this plan?
A. Moderate level
Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B. High level
A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C. No risk
This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D. Low level
Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.
Full Explanation
A. Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B. A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C. This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D. Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.
A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?
A. Patient is attempting to use relaxation strategies.
Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B. Patient is demonstrating withdrawal behaviors.
Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C. Patient is exhibiting clues to potential aggression.
The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D. Patient is trying to work through angry feelings.
Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.
Full Explanation
A. Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B. Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C. The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D. Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.