Nursing Elites

1. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to discuss the thoughts and feelings behind the behavior.
• C. Restrict the client's access to the locks.
• D. Schedule specific times for the client to check the locks.

Correct answer: B

Rationale: The most therapeutic nursing intervention for a client with obsessive-compulsive disorder (OCD) who repeatedly checks locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can work towards understanding and managing their compulsions. Choice A is incorrect because allowing the client to continue the behavior does not address the root cause or help modify the behavior. Choice C is inappropriate as restricting access to locks can increase anxiety and worsen symptoms. Choice D of scheduling specific times for checking locks does not address the underlying psychological issues driving the behavior.

2. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

3. The nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, 'Get out of here! I'll get up when I'm ready!' Which response is best for the nurse to make?

• A. Your healthcare provider has prescribed ambulation on the first postoperative day.
• B. You must ambulate to avoid complications that could cause more discomfort than ambulating.
• C. I know how you feel. You're angry about having to ambulate, but this will help you get well.
• D. I'll be back in 30 minutes to help you get out of bed and walk around the room.

Correct answer: D

Rationale: (D) provides a 'cooling off' period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with an intellectually disabled client and is threatening the client with 'complications.' (C) is telling the client how she feels (angry), and the nurse does not really 'know' how this client feels, unless the nurse is also intellectually disabled and has also just had an appendectomy.

4. A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?

• A. I don't hear any voices. They must be in your head.
• B. What are the voices telling you to do?
• C. You need to ignore the voices and focus on reality.
• D. I know the voices are real to you, but I don't hear them.

Correct answer: D

Rationale: Acknowledging the client's experience while gently presenting reality can help build trust and provide reassurance without reinforcing the hallucination.

5. The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance abuse places the client at the highest risk for myocardial infarction?

• A. Benzodiazepines
• B. Marijuana
• C. Methamphetamine
• D. Alcohol

Correct answer: C

Rationale: Methamphetamine use is strongly associated with cardiovascular risks, including myocardial infarction, due to its stimulant effects on the heart. Benzodiazepines (Choice A) are not typically associated with an increased risk of myocardial infarction. Marijuana (Choice B) is not commonly linked to heart attacks, though it can have other health effects. Alcohol (Choice D) abuse can lead to cardiovascular issues, but methamphetamine has a more direct and potent impact on the heart, making it the highest risk factor in this scenario.

Similar Questions