Nursing Elites

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

• A. Encourage the client to wash her hands less frequently.
• B. Set a time limit for hand washing.
• C. Teach the client relaxation techniques.
• D. Discourage the client from washing her hands.

Correct answer: B

Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.

2. A patient with schizophrenia is experiencing hallucinations. Which intervention is most appropriate?

• A. Encourage the patient to ignore the voices.
• B. Engage the patient in a reality-based activity.
• C. Provide a quiet environment to reduce stimulation.
• D. Ask the patient to describe the hallucinations in detail.

Correct answer: B

Rationale: Engaging the patient in a reality-based activity is the most appropriate intervention for a patient with schizophrenia experiencing hallucinations. This intervention can help distract the patient from the hallucinations and reorient them to the present, promoting a connection with reality and potentially reducing distress associated with the hallucinations. Choice A, encouraging the patient to ignore the voices, may not be effective as it can be challenging for the patient to dismiss the hallucinations. Choice C, providing a quiet environment, is helpful but may not directly address the hallucinations. Choice D, asking the patient to describe the hallucinations in detail, may increase the patient's focus on the hallucinations, potentially worsening distress.

3. A client is diagnosed with somatic symptom disorder. Which question will help the nurse develop nursing diagnoses for this client’s plan of care?

• A. Are you satisfied with your appearance?
• B. Do you take medication for anxiety as prescribed?
• C. When did you last feel detached from your environment?
• D. How long have you had these memory problems?

Correct answer: B

Rationale: In clients with somatic symptom disorder, it is crucial to assess their adherence to medication for anxiety as prescribed. This question helps the nurse understand the client's treatment compliance, which can impact the development of nursing diagnoses and the overall plan of care. Monitoring medication adherence is essential in managing the client's symptoms and improving outcomes.

4. Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

• A. The patient's verbal and nonverbal communication is often different.
• B. When my patient responds to my question, I check for congruence between verbal and nonverbal communication to help validate the response.
• C. If a patient is slumped in the chair, I can be sure he's angry or depressed.
• D. It's easier to understand verbal communication than nonverbal communication.

Correct answer: B

Rationale: Checking for congruence between verbal and nonverbal communication helps validate the patient's response.

5. A client diagnosed with panic disorder is receiving discharge teaching from a healthcare provider. Which statement by the client indicates an accurate understanding of the teaching?

• A. I should avoid caffeine and other stimulants.
• B. I should take my medication only when I feel anxious.
• C. I should use relaxation techniques to manage anxiety.
• D. I should avoid exercising to prevent triggering anxiety.

Correct answer: A

Rationale: The correct answer is A. Avoiding caffeine and other stimulants is crucial for clients with panic disorder as these substances can exacerbate anxiety symptoms. Caffeine can trigger or worsen anxiety, leading to increased heart rate and restlessness. By eliminating stimulants, the client can better manage their anxiety levels and reduce the risk of panic attacks. Choices B, C, and D are incorrect because taking medication only when feeling anxious may lead to inconsistent treatment, using relaxation techniques alone may not be sufficient for managing panic disorder, and avoiding exercise can actually be counterproductive as regular physical activity can help reduce anxiety and stress levels.

Similar Questions