Nursing Elites

1. A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Set strict limits on the time allowed for handwashing.
• C. Distract the client with other activities.
• D. Encourage the client to participate in a support group.

Correct answer: A

Rationale: Initially, it is most appropriate to allow the client to continue the behavior to reduce anxiety (A). For clients with OCD, abruptly stopping compulsive behaviors can lead to increased anxiety and distress. Setting strict limits (B) may exacerbate anxiety at first. Distraction with other activities (C) may not address the underlying issue effectively. While support groups (D) can be beneficial, they are typically introduced after establishing trust and gradually working on reducing compulsive behaviors.

2. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?

• A. I would be very upset and mad if my best friend did that to me.
• B. You must feel betrayed, but maybe you might have led him on?
• C. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
• D. This does not sound like rape. Did you change your mind about having sex after the fact?

Correct answer: C

Rationale: A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. Choice (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (Choice A) when dealing with victims. Choice B, suggesting that the client led on the rapist, indicates that the sexual assault was somehow the victim's fault. Choice D is judgmental and does not display compassion or establish trust between the nurse and the client.

3. The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is best for the LPN/LVN to provide to this family member?

• A. It sounds like you're worried about your husband. Let's sit down and talk.
• B. It is a chemical imbalance in the brain that causes disorganized thinking.
• C. Your husband will be just fine if he takes his medications regularly.
• D. I think you should talk to your husband's psychologist about this question.

Correct answer: B

Rationale: The best response for the LPN/LVN to provide to the wife of a male client diagnosed with schizophrenia is choice B: 'It is a chemical imbalance in the brain that causes disorganized thinking.' This response educates the wife about the nature of schizophrenia, explaining that it is caused by a chemical imbalance in the brain leading to disorganized thinking, helping her understand the condition better. Choice A does not directly address the question and instead shifts the focus to a different aspect. Choice C gives false reassurance without providing necessary information about schizophrenia. Choice D deflects the responsibility of providing information to the psychologist instead of addressing the wife's concerns directly.

4. What is the priority intervention for a client with major depressive disorder admitted to the psychiatric unit with suicidal ideation?

• A. Conduct a thorough suicide risk assessment.
• B. Encourage the client to verbalize their feelings.
• C. Provide the client with positive affirmations.
• D. Refer the client to group therapy.

Correct answer: A

Rationale: The correct answer is to conduct a thorough suicide risk assessment. When a client with major depressive disorder presents with suicidal ideation, the priority is to assess the level of risk to ensure the client's safety. This assessment helps determine the appropriate interventions, level of care, and monitoring needed. Encouraging the client to verbalize their feelings (choice B) is important, but not the priority when immediate safety is a concern. Providing positive affirmations (choice C) and referring the client to group therapy (choice D) may be beneficial interventions later on but do not address the immediate risk of harm to the client.

5. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

• A. Attempt to ask the client simple questions.
• B. Postpone the client interview until the next day.
• C. Ask another nurse to talk with the client.
• D. Document the client's paranoid behavior.

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

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