Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The RN learns that the father of a teenage client was killed in a car accident when he was a baby, and his mother has raised him on her own.
How should the nurse interpret this family’s functionality?
A. The teenager is probably difficult for a single mother to manage, so the family will be referred to social services.
Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.
B. Further assessment needs to be done to determine if the family needs assistance.
This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.
C. The mother needs assistance to cope with the stress of raising a teenager on her own.
Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.
D. The mother will need financial support while she takes off work to care for her son.
Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.
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Full Explanation
This is because the nurse should not make assumptions about the family’s functionality based on their history or situation, but rather gather more information to identify their strengths and needs.
Choice A is wrong because it implies that the teenager is a problem and the mother is incapable of managing him, which is disrespectful and judgmental.
Choice C is wrong because it assumes that the mother is stressed and needs coping skills, which may not be true.
Choice D is wrong because it suggests that the mother is financially dependent on her son, which is not relevant to the question.
Similar Questions
Which of the following nursing diagnoses would typically NOT be associated with anemia?
A. Ineffective tissue perfusion.
Choice A. Ineffective tissue perfusion is wrong because anaemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.
B. Activity intolerance.
Choice B. Activity intolerance is wrong because anaemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.
C. Fluid volume deficit.
This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.
D. Risk for decreased cardiac output.
Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.
Full Explanation
This nursing diagnosis is typically not associated with anemia because anemia does not cause dehydration or loss of body fluids. Anemia is a condition in which the hemoglobin concentration or the number of red blood cells is lower than normal, resulting in decreased oxygen delivery to the tissues.
Choice A. Ineffective tissue perfusion is wrong because anemia can impair tissue perfusion by reducing the oxygen-carrying capacity of the blood.
Choice B. Activity intolerance is wrong because anemia can cause fatigue, weakness, and dyspnea on exertion due to inadequate oxygen supply to the muscles.
Choice D. Risk for decreased cardiac output is wrong because anemia can increase the risk of cardiac complications such as tachycardia, palpitations, angina, and heart failure due to increased cardiac workload and demand for oxygen.
Normal ranges for hemoglobin are 13.5 to 17.5 g/dL for men and 12 to 15.5 g/dL for women; normal ranges for hematocrit are 38.8 to 50% for men and 34.9 to 44.5% for women; normal ranges for red blood cell count are 4.7 to 6.1 million/mm3 for men and 4.2 to 5.4 million/mm3 for women; normal ranges for reticulocyte count are 0.5 to 1.5% of red blood cells.
A client’s bloodwork indicates that he has severe hypokalemia.
What is a priority nursing intervention?
A. Place the client on a cardiac monitor.
This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.
B. Administer a laxative as ordered.
Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.
C. Place the client on seizure precautions.
Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.
D. Restrict high potassium foods.
Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels. Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.
Full Explanation
This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.
Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.
Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.
Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.
Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.
A public health nurse is assessing an older adult client who lives with a family member.
The nurse identifies several bruises in various stages of healing. The client and family members explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse.
Which of the following actions should the nurse take first?
A. Investigate further to confirm the suspicion.
Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.
B. Report the findings.
The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.
C. Provide the client with a crisis hotline number.
Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being. The client might not be able to access the hotline or might be afraid to use it.
D. Discuss respite care with the client’s family.
Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage. The nurse should not assume that the family member is willing or able to provide adequate care for the client. Respite care might be an option after the abuse is reported and investigated.
Full Explanation
The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.
Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.
Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.
The client might not be able to access the hotline or might be afraid to use it.
Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.
The nurse should not assume that the family member is willing or able to provide adequate care for the client.
Respite care might be an option after the abuse is reported and investigated.