Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30, and BP 160/90. The patient states that he feels something bad is about to happen. Based on this data alone, how should the nurse identify the patient's level of anxiety?
A. Moderate
Moderate: Moderate anxiety typically involves increased alertness and focus, not severe physiological changes.
B. Panic
Panic: Panic is characterized by extreme dread and inability to function, often with a sense of unreality.
C. Mild
Mild: Mild anxiety involves slight discomfort and can enhance learning and performance.
D. Severe
Severe: Severe anxiety includes significant physiological responses (elevated vital signs) and a sense of impending doom.
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Full Explanation
A. Moderate: Moderate anxiety typically involves increased alertness and focus, not severe physiological changes.
B. Panic: Panic is characterized by extreme dread and inability to function, often with a sense of unreality.
C. Mild: Mild anxiety involves slight discomfort and can enhance learning and performance.
D. Severe: Severe anxiety includes significant physiological responses (elevated vital signs) and a sense of impending doom.
Similar Questions
A nurse is caring for a patient who has anxiety attacks. What symptoms would indicate that the patient is experiencing a severe anxiety attack?
A. The patient has decreased perceptions.
The patient has decreased perceptions: This is a sign of panic anxiety, not necessarily severe anxiety.
B. The patient has increased motivation.
The patient has increased motivation: Increased motivation is associated with mild to moderate anxiety.
C. The patient has feeling of impending doom.
The patient has a feeling of impending doom: This is a hallmark of severe anxiety, characterized by intense fear and a sense of catastrophic events.
D. The patient could cause harm to self or others.
The patient could cause harm to self or others: This is more indicative of panic or extreme anxiety with loss of control.
Full Explanation
A. The patient has decreased perceptions: This is a sign of panic anxiety, not necessarily severe anxiety.
B. The patient has increased motivation: Increased motivation is associated with mild to moderate anxiety.
C. The patient has a feeling of impending doom: This is a hallmark of severe anxiety, characterized by intense fear and a sense of catastrophic events.
D. The patient could cause harm to self or others: This is more indicative of panic or extreme anxiety with loss of control.
When a patient is experiencing a panic attack, how should the nurse best assist the patient?
A. Assist with reality orientation.
Assist with reality orientation: Reality orientation is more suitable for psychotic disorders or delirium.
B. Coach in deep breathing.
Coach in deep breathing: Deep breathing helps to calm the patient and reduce the physiological symptoms of a panic attack.
C. Assist with rational thought.
Assist with rational thought: Rational thought is difficult to achieve during a panic attack; calming measures are more appropriate.
D. Aid in decision making.
Aid in decision making: Decision-making assistance is not practical during a panic attack when the patient is highly distressed.
Full Explanation
A. Assist with reality orientation: Reality orientation is more suitable for psychotic disorders or delirium.
B. Coach in deep breathing: Deep breathing helps to calm the patient and reduce the physiological symptoms of a panic attack.
C. Assist with rational thought: Rational thought is difficult to achieve during a panic attack; calming measures are more appropriate.
D. Aid in decision making: Decision-making assistance is not practical during a panic attack when the patient is highly distressed.
Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure injuries, the nurse alters the care plan to include turning the bedfast patient how often?
A. Each evening
Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift
Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours
Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours
Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.
Full Explanation
A. Each evening: Turning the patient only once per day is insufficient to prevent pressure injuries.
B. Once every shift: This is also inadequate as it does not provide the frequent repositioning necessary to prevent pressure injuries.
C. Every 4 hours: While better than every shift, every 4 hours may still not be frequent enough to prevent pressure injuries in at-risk patients.
D. Every 2 hours: Frequent repositioning, such as every 2 hours, is essential for pressure injury prevention in bedfast patients.