Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
What is the priority finding to report to other disciplines for a client who has major depressive disorder?
A. Significant weight loss
Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.
B. Markedly neglected hygiene
C. Psychomotor retardation
D. Poor problem-solving skills
This question is an excerpt from Nurse Dive's nursing test bank - RN Mental Health 2019 With NGN Proctored Exam. Take the full exam now
Full Explanation
Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.
Similar Questions
Who should the nurse contact to assist the client with housing placement for discharge?
A. Recreational therapist
B. Occupational therapist
C. Clinical nurse specialist
D. Social worker
This team member can help the client find appropriate and affordable housing options, as well as connect them with community resources and support services. The other team members have different roles in the client's care, such as providing recreational activities, occupational skills, or specialized nursing interventions.
Full Explanation
This team member can help the client find appropriate and affordable housing options, as well as connect them with community resources and support services. The other team members have different roles in the client's care, such as providing recreational activities, occupational skills, or specialized nursing interventions.
What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?
A. Sore throat
This finding could indicate agranulocytosis, a potentially life-threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.
B. Heart rate 104/min
C. Nausea
D. Random blood glucose 130 mg/dL
Full Explanation
This finding could indicate agranulocytosis, a potentially life threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
A. Obtain the provider's prescription within 60 min.
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
B. Document the client's behavior every 15 min.
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
C. Monitor the client's vital signs every 4 hr.
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
D. Offer the client food and fluids every 2 hr.
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.
Full Explanation
Choice A reason:
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
Choice B reason:
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
Choice C reason:
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
Choice D reason:
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.