Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When the practical nurse (PN) atempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!"
Which response is best for the PN to make?
A. A. "You must ambulate to avoid complications which could cause more discomfort than ambulating."
It uses a threatening tone and does not acknowledge the client's feelings.
B. B. "I know you feel angry about the pain of ambulation, but this is a necessary part of getting well."
It uses a threatening tone and does not acknowledge the client's feelings.
C. C. "Your healthcare provider has left specific instructions to ambulate on the first postoperative day."
It appeals to authority and does not explain the rationale or benefits of ambulation.
D. D. "I will be back in 30 minutes to help you get out of bed and walk around the room today."
An 18-year-old client with a mild mental disability is a client who has a lower than average intellectual functioning and some limitations in adaptive skills, such as communication, socialization, and self-care. A mild mental disability may affect the client's ability to understand, cope, or cooperate with medical interventions, such as ambulation after surgery. Ambulation is the act of walking or moving around. It is an important part of postoperative care, as it helps to prevent complications such as deep vein thrombosis, pulmonary embolism, pneumonia, atelectasis, constipation, and pressure ulcers. Ambulation also promotes circulation, wound healing, and muscle strength. When the practical nurse (PN) atempts to assist the client to ambulate on the first postoperative day after an appendectomy, the client becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" This may indicate that the client is experiencing pain, fear, anxiety, or frustration due to the surgery and the recovery process . The best response for the PN to make is to acknowledge the client's feelings, provide reassurance and support, and set a clear and realistic goal for ambulation. This will help to establish rapport, reduce resistance, and motivate the client to participate in the care plan. Therefore, option D is the correct answer, as it shows empathy and respect for the client's feelings, while also informing the client of the expectation and time frame for ambulation. Option D also allows the client some time to prepare mentally and physically for the activity.
This question is an excerpt from Nurse Dive's nursing test bank - HESI PN Exit 2023 Proctored Exam. Take the full exam now
Full Explanation
An 18-year-old client with a mild mental disability is a client who has a lower than average intellectual functioning and some limitations in adaptive skills, such as communication, socialization, and self-care. A mild mental disability may affect the client's ability to understand, cope, or cooperate with medical interventions, such as ambulation after surgery.
Ambulation is the act of walking or moving around. It is an important part of postoperative care, as it helps to prevent complications such as deep vein thrombosis, pulmonary embolism, pneumonia, atelectasis, constipation, and pressure ulcers. Ambulation also promotes circulation, wound healing, and muscle strength.
When the practical nurse (PN) atempts to assist the client to ambulate on the first postoperative day after an appendectomy, the client becomes angry and says, "PN, 'Get out of here! I'll get up when I'm ready!" This may indicate that the client is experiencing pain, fear, anxiety, or frustration due to the surgery and the recovery process .
The best response for the PN to make is to acknowledge the client's feelings, provide reassurance and support, and set a clear and realistic goal for ambulation. This will help to establish rapport, reduce resistance, and motivate the client to participate in the care plan.
Therefore, option D is the correct answer, as it shows empathy and respect for the client's feelings, while also informing the client of the expectation and time frame for ambulation. Option D also allows the client some time to prepare mentally and physically for the activity.
Similar Questions
A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
A. Client's healthcare power of attorney.
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
B. Fall at home as reason for admission.
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
C. Currently prescribed medications.
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
D. Increasing confusion of the client.
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
E. Increasing confusion of the client.
Full Explanation
Choice A rationale:
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
Choice B rationale:
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
Choice C rationale:
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
Choice D rationale:
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
A nurse is teaching a client with hypertension about antihypertensive drugs.
Which of the following statements by the client indicates an understanding of the teaching?
A. “Antihypertensive drugs work by increasing the blood flow to my heart and kidneys.”
This statement is incorrect. Antihypertensive drugs typically work by reducing blood pressure through various mechanisms, such as dilating blood vessels, reducing blood volume, or affecting the heart's workload. They do not increase blood flow to the heart and kidneys.
B. “Antihypertensive drugs can lower my blood pressure by affecting different parts of my cardiovascular system.”
This is the correct answer. Antihypertensive drugs work by affecting different aspects of the cardiovascular system, such as reducing blood vessel constriction (vasodilation), decreasing blood volume, or slowing the heart rate. By affecting these components, they can lower blood pressure.
C. “Antihypertensive drugs are safe to use with any other medications or supplements I might take.”
This statement is incorrect. Antihypertensive drugs can interact with other medications or supplements, potentially causing adverse effects or drug interactions. It's essential for the client to inform their healthcare provider of all medications and supplements they are taking to ensure safe and effective treatment.
D. “Antihypertensive drugs will cure my hypertension if I take them as prescribed.”.
This statement is incorrect. Antihypertensive drugs do not cure hypertension but help control it. Clients need to understand that they will likely need to take these medications long-term to manage their blood pressure effectively.
E. “Antihypertensive drugs will cure my hypertension if I take them as prescribed.”.
Full Explanation
Choice A rationale:
This statement is incorrect. Antihypertensive drugs typically work by reducing blood pressure through various mechanisms, such as dilating blood vessels, reducing blood volume, or affecting the heart's workload. They do not increase blood flow to the heart and kidneys.
Choice B rationale:
This is the correct answer. Antihypertensive drugs work by affecting different aspects of the cardiovascular system, such as reducing blood vessel constriction (vasodilation), decreasing blood volume, or slowing the heart rate. By affecting these components, they can lower blood pressure.
Choice C rationale:
This statement is incorrect. Antihypertensive drugs can interact with other medications or supplements, potentially causing adverse effects or drug interactions. It's essential for the client to inform their healthcare provider of all medications and supplements they are taking to ensure safe and effective treatment.
Choice D rationale:
This statement is incorrect. Antihypertensive drugs do not cure hypertension but help control it. Clients need to understand that they will likely need to take these medications long-term to manage their blood pressure effectively.
A nurse is teaching a group of older adults about the effects of aging on the neurological system.
Which of the following statements should the nurse include as correct? (Select all that apply.).
A. “You may notice that your reaction time is slower than before.”.
Slower reaction time is a common age-related change in the neurological system. The processing of sensory information and response time may become slower in older adults due to changes in neural pathways and decreased neurotransmitter activity.
B. “You may experience some difficulty with learning new things.”.
Older adults may experience some difficulty with learning new things due to changes in cognitive function and neural plasticity. This is a common age-related effect on the neurological system.
C. “You may have more neurotransmitters in your brain as you age.”.
This statement is incorrect. Older adults typically have fewer neurotransmitters in their brains as they age, which can contribute to cognitive changes and a decline in cognitive function.
D. “You may lose some of your sense of smell and taste over time.”.
Loss of some sense of smell and taste is an age-related change. Older adults may experience a decreased ability to detect and differentiate smells and tastes due to changes in olfactory and gustatory receptors.
E. “You may have more oxygen delivery to your brain cells as you age.”.
This statement is incorrect. Aging does not necessarily lead to an increase in oxygen delivery to brain cells. In fact, there may be a decrease in cerebral blood flow with age in some individuals.
Full Explanation
Choice A rationale:
Slower reaction time is a common age-related change in the neurological system. The processing of sensory information and response time may become slower in older adults due to changes in neural pathways and decreased neurotransmitter activity.
Choice B rationale:
Older adults may experience some difficulty with learning new things due to changes in cognitive function and neural plasticity. This is a common age-related effect on the neurological system.
Choice C rationale:
This statement is incorrect. Older adults typically have fewer neurotransmitters in their brains as they age, which can contribute to cognitive changes and a decline in cognitive function.
Choice D rationale:
Loss of some sense of smell and taste is an age-related change. Older adults may experience a decreased ability to detect and differentiate smells and tastes due to changes in olfactory and gustatory receptors.
Choice E rationale:
This statement is incorrect. Aging does not necessarily lead to an increase in oxygen delivery to brain cells. In fact, there may be a decrease in cerebral blood flow with age in some individuals.