Nursing Elites

1. A client with obsessive-compulsive disorder (OCD) spends hours each day washing her hands. Which intervention should the nurse implement to help the client reduce this behavior?

• A. Encourage the client to set a time limit for washing hands.
• B. Encourage the client to wash hands only when necessary.
• C. Encourage the client to use hand sanitizer instead of washing.
• D. Encourage the client to explore the reasons behind the hand washing.

Correct answer: A

Rationale: Setting a time limit for hand washing is an effective intervention in managing obsessive-compulsive disorder (OCD) symptoms. By establishing boundaries around the behavior, the client can gradually work towards reducing the excessive hand washing and regaining control over the compulsion. Choice B is not as effective because it does not address the underlying compulsion. Choice C may not be helpful as it may not satisfy the client's need for cleanliness and could reinforce the behavior. Choice D, while important in therapy, may not be the most immediate intervention needed to address the excessive hand washing behavior.

2. A client diagnosed with schizophrenia is receiving discharge teaching. Which of the following instructions should the nurse exclude?

• A. Continue taking medications as prescribed
• B. Avoid all social interactions
• C. Report any side effects of medications to the healthcare provider
• D. Develop a daily routine

Correct answer: B

Rationale: The nurse should exclude the instruction to 'Avoid all social interactions' when providing discharge teaching to a client with schizophrenia. It's important for individuals with schizophrenia to continue taking medications as prescribed, report any medication side effects to the healthcare provider, and develop a daily routine to promote stability. Social interactions, albeit with appropriate boundaries, can be beneficial for the client's well-being and integration into the community.

3. When explaining suicide precautions to a client, what would be the best explanation?

• A. You need to control yourself. If you cannot, we will do it for you.
• B. This can seem embarrassing, but we want you to be safe.
• C. You will stay on these precautions for one week.
• D. When you feel you are safer, then we will not need to observe you.

Correct answer: D

Rationale: Choice D provides a supportive and empowering explanation to the client on suicide precautions. It emphasizes the client's own sense of safety and control, indicating that the observation is temporary and can be removed when the client feels safer. This approach promotes autonomy and encourages the client to actively participate in their own well-being, fostering a therapeutic relationship based on trust and collaboration.

4. A client displays signs and symptoms indicative of hypochondriasis. The nurse would initially expect to see:

• A. Self-preoccupation
• B. La belle indifference
• C. Fear of physicians
• D. Insight into the source of their fears

Correct answer: A

Rationale: In hypochondriasis, individuals are excessively preoccupied with and worried about having a serious illness, despite reassurance from medical professionals. This self-preoccupation is a key characteristic of hypochondriasis. 'La belle indifference' refers to a lack of concern or distress about symptoms, which is not typically seen in hypochondriasis. Fear of physicians may be present due to the individual's persistent belief in their illness despite medical reassurance. Insight into the source of their fears is usually lacking in hypochondriasis, as individuals often believe their physical symptoms are evidence of a serious illness.

5. A nurse is assessing a patient with schizophrenia who is experiencing delusions. Which intervention is most appropriate?

• A. Agree with the patient's delusions to avoid confrontation.
• B. Encourage the patient to explore the basis of the delusions.
• C. Engage the patient in reality-based activities.
• D. Ask the patient to explain the delusions in detail.

Correct answer: C

Rationale: The most appropriate intervention when assessing a patient with schizophrenia experiencing delusions is to engage the patient in reality-based activities. This intervention helps distract the patient from the delusions and reorients them to the present, promoting grounding in reality. Choice A is incorrect because agreeing with delusions can reinforce them and hinder treatment. Choice B may exacerbate the delusions by delving deeper into their basis. Choice D may not be beneficial as it focuses solely on the delusions without addressing the need to ground the patient in reality.

Similar Questions