Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse observes the client as he paces the floor and talks to himself. The nurse documents this as "Client confused and agitated." This is an example of
A. An observation
An observation is a factual statement of what the nurse sees, hears, feels, or smells.
B. A judgment
This is because the nurse is interpreting the client's behavior and not describing it objectively.
C. Subjective data
subjective data is information that the client tells the nurse, such as feelings, perceptions, or opinions.
D. Objective data
Objective data is information that the nurse obtains through physical examination, tests, or measurements.
This question is an excerpt from Nurse Dive's nursing test bank - ATI ns 130 Exam Psychosocial Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale: An observation is a factual statement of what the nurse sees, hears, feels, or smells.
Choice B rationale: This is because the nurse is interpreting the client's behavior and not describing it objectively.
Choice C rationale: subjective data is information that the client tells the nurse, such as feelings, perceptions, or opinions.
Choice D rationale: Objective data is information that the nurse obtains through physical examination, tests, or measurements.
Similar Questions
Lability is described as a rapid change in emotions. True or False
A. True
B. False
Full Explanation
Lability refers to the rapid and unpredictable shift in an individual’s emotional states, for instance, an individual may move from laughing to crying within a span of seconds with no apparent reason. This may affect the individual’s ability to function and cope with daily life, as well as their relationships with others. It is caused by conditions such as brain injury, neurological disorders, mood disorders, or substance abuse.
The nurse should monitor the temperature of the environment of a client who becomes easily agitated, with awareness that increased temperatures sometimes may cause the client to become:
A. Calm
High temperatures do not usually cause people to become calm unless they are suffering from heat exhaustion or heat stroke, which are medical emergencies.
B. Depressed
depression is usually associated with low temperatures and reduced sunlight exposure rather than high temperatures.
C. Agitated
high temperatures is associated with arousal and agitation in some individuals which may be due to the effects of heat on the individual’s nervous system, cardiovascular, and endocrine systems.
D. Confused
confusion is not usually associated with confusion. However, it may result in confusion in older adults and individuals with other underlying conditions.
Full Explanation
Choice A rationale: High temperatures do not usually cause people to become calm unless they are suffering from heat exhaustion or heat stroke, which are medical emergencies.
Choice B rationale: depression is usually associated with low temperatures and reduced sunlight exposure rather than high temperatures.
Choice C rationale: high temperatures is associated with arousal and agitation in some individuals which may be due to the effects of heat on the individual’s nervous system, cardiovascular, and endocrine systems.
Choice D rationale: confusion is not usually associated with confusion. However, it may result in confusion in older adults and individuals with other underlying conditions.
During client teaching, the nurse must inform the client prescribed a tricyclic antidepressant (TCA) to not expect to see a difference in mood or anxiety level for up to:
A. 2-4 weeks
TCAs do not have an immediate mechanism of action and may take approximately 2-4 weeks to have an effect on the neurotransmitters involved in mood regulation hence the brain may take some time to adjust to these changes.
B. 1-2 weeks
1-2 weeks is too short, and may lead clients to feel discouraged or frustrated if they do not see any results by then hence informing them of the duration it will take before they can realize a change in their mood or anxiety is crucial.
C. 3-4 days
3-4 days is too short, and may lead clients to feel discouraged or frustrated if they do not see any results.
D. 1-2 days
1-2 days is too short and unrealistic and gives the client false expectations and may make them think that the drugs are ineffective in their mood and anxiety control.
Full Explanation
Choice A rationale: TCAs do not have an immediate mechanism of action and may take approximately 2-4 weeks to have an effect on the neurotransmitters involved in mood regulation hence the brain may take some time to adjust to these changes.
Choice B rationale: 1-2 weeks is too short, and may lead clients to feel discouraged or frustrated if they do not see any results by then hence informing them of the duration it will take before they can realize a change in their mood or anxiety is crucial.
Choice C rationale: 3-4 days is too short, and may lead clients to feel discouraged or frustrated if they do not see any results.
Choice D rationale: 1-2 days is too short and unrealistic gives the client false expectations and may make them think that the drugs are ineffective in their mood and anxiety control.