Nursing Elites

1. A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?

• A. Allow the client to pace in a safe environment.
• B. Encourage the client to discuss feelings.
• C. Help the client identify the cause of anxiety.
• D. Provide a distraction for the client.

Correct answer: A

Rationale: Allowing the client to pace in a safe environment is an appropriate nursing intervention for managing moderate anxiety levels. Allowing pacing provides the client with a physical outlet for their anxiety and can help them release nervous energy without increasing distress. It promotes movement and can aid in reducing feelings of restlessness or agitation. Encouraging the client to discuss feelings (Choice B) is more suitable for addressing emotional aspects of anxiety rather than providing an immediate physical outlet. Helping the client identify the cause of anxiety (Choice C) may be more appropriate for long-term management but may not address the immediate need for physical release. Providing a distraction (Choice D) may not directly address the physical needs associated with moderate anxiety levels.

2. In a client with obsessive-compulsive disorder (OCD) undergoing cognitive-behavioral therapy, which outcome indicates that the therapy is effective?

• A. The client reports a decrease in the frequency of compulsive behaviors.
• B. The client reports a decrease in the intensity of obsessive thoughts.
• C. The client reports an improvement in overall mood.
• D. The client reports an improvement in sleep patterns.

Correct answer: A

Rationale: In clients with OCD undergoing cognitive-behavioral therapy, a decrease in the frequency of compulsive behaviors is a key indicator of treatment effectiveness. This reduction signifies progress in managing and controlling the compulsions associated with OCD, which is a primary goal of the therapy. Choices B, C, and D may also be positive outcomes of therapy, but the most critical aspect in treating OCD with cognitive-behavioral therapy is targeting and reducing the frequency of compulsive behaviors.

3. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?

• A. Allow the client to continue the ritualistic behavior initially
• B. Immediately stop the client from performing the ritual
• C. Encourage the client to perform the ritual more quickly
• D. Provide a distraction to interrupt the ritual

Correct answer: A

Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.

4. When assessing a patient with major depressive disorder, which symptom would most likely be observed?

• A. Euphoria
• B. Anhedonia
• C. Increased energy
• D. Racing thoughts

Correct answer: B

Rationale: Anhedonia, the inability to feel pleasure in activities that were once enjoyable, is a hallmark symptom of major depressive disorder. Patients with major depressive disorder often experience a pervasive feeling of emptiness and loss of interest in activities they used to find pleasurable. Euphoria, increased energy, and racing thoughts are more commonly associated with conditions like bipolar disorder rather than major depressive disorder.

5. A psychiatric nurse observes that a client diagnosed with schizophrenia is pacing up and down the corridor. The client is muttering to himself, and his hands are trembling. Which of the following actions should the nurse take first?

• A. Ask the client if he is hearing voices.
• B. Offer the client a PRN medication for anxiety.
• C. Encourage the client to participate in a relaxation exercise.
• D. Remove the client to a quieter environment.

Correct answer: D

Rationale: The first action the nurse should take is to remove the client to a quieter environment. This intervention aims to reduce stimuli that may be contributing to the client's agitation and help create a calmer and more supportive setting for the client. Choices A, B, and C are not the priority in this situation as addressing the environmental factors should come first before exploring symptoms, offering medication, or engaging in relaxation exercises.

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