a client with obsessive compulsive disorder ocd spends several hours a day washing his hands what is the most therapeutic nursing intervention a client with obsessive compulsive disorder ocd spends several hours a day washing his hands what is the most therapeutic nursing intervention
Logo

Nursing Elites

HESI LPN

HESI Mental Health Practice Exam

1. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?

Correct answer: C

Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.

2. A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?

Correct answer: D

Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.

3. The _____ is the inner layer of the embryo from which the lungs and digestive system develop.

Correct answer: C

Rationale: The endoderm is the correct answer. It is the innermost layer of the embryo that gives rise to organs such as the lungs, digestive system, liver, and pancreas. The neural tube (Choice A) forms the brain and spinal cord, not the lungs or digestive system. Mesoderm (Choice B) develops into structures like muscles, bones, and circulatory system, not the lungs or digestive system. The umbilical cord (Choice D) serves as a connection between the embryo and the placenta, providing nutrients and oxygen, but it is not the layer from which lungs and digestive system develop.

4. What is a common symptom of congenital heart disease in infants?

Correct answer: B

Rationale: Difficulty breathing is a common symptom of congenital heart disease in infants. Infants with congenital heart disease may experience difficulty breathing due to impaired cardiac function, which affects the heart's ability to pump blood effectively. This symptom is often due to issues like heart failure or fluid accumulation in the lungs. Excessive weight gain (Choice A) is not typically associated with congenital heart disease in infants. High blood pressure (Choice C) is less common in infants with congenital heart disease compared to adults. Increased appetite (Choice D) is not a typical symptom of congenital heart disease in infants.

5. The nurse is taking a history for a female client who is requesting a routine female exam. Which assessment finding requires follow-up?

Correct answer: D

Rationale: The correct answer is D. Experiencing a 'black-out' after consuming only one drink is highly unusual and may indicate the client was drugged, necessitating immediate follow-up. Menstruation onset at age 9 and a menstrual cycle occurring every 35 days, although on the outer ranges of 'average,' are within acceptable norms. Relying solely on condoms as a contraceptive method increases the risk of conception.

Similar Questions

A client has right-sided paralysis following a cerebrovascular accident. Which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
Which of the following BEST describes the strategies to address the nutrition problems of Filipinos related to non-communicable diseases?
A healthcare provider is assessing a newborn immediately following a vaginal birth. For which of the following findings should the provider intervene?
A client with a diagnosis of depression is prescribed escitalopram. Which statement by the client indicates the need for further teaching?

Access More Features

HESI Basic

HESI Basic