Nursing Elites

1. A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (select one that does not apply.)

• A. Compulsions relieve anxiety
• B. Anxiety is the key reason for OCD
• C. Obsessions cause compulsions
• D. Obsessive thoughts are linked to levels of neurochemicals

Correct answer: C

Rationale: The correct answer is C. Obsessions do not cause compulsions; rather, obsessions are intrusive, unwanted thoughts, images, or urges that trigger intensely distressing feelings, while compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Choices A, B, and D are incorrect. Choice A is incorrect because compulsions are behaviors or mental acts aimed at reducing distress or preventing a dreaded event or situation. Choice B is incorrect because while anxiety is often a significant component of OCD, it is not the only reason for the disorder. Choice D is incorrect because obsessive thoughts are not solely linked to levels of neurochemicals but are more complex and multifactorial.

2. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, 'No, it's not MY fault. You can't blame me. I didn't kill him, you did.' What action is best for the nurse to take?

• A. Reassure the client by telling him that his fear of the admission procedure is to be expected.
• B. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
• C. Assess the content of the hallucinations by asking the client what he is hearing.
• D. Ignore the behavior and make no response at all to his delusional statements.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to assess the content of the hallucinations by asking the client what he is hearing (C). Further assessment is needed to understand the nature of the client's delusions and hallucinations. Choice A is incorrect as it focuses on reassuring the client about his fear, which is not addressing the underlying issue of the delusional statement. Choice B is incorrect as it argues with the client's delusion and offers false reassurance, which is not therapeutic. Choice D is incorrect as ignoring the behavior and making no response disregards the client's needs for assessment and support.

3. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

• A. Dizziness when standing.
• B. Shuffling gait and hand tremors.
• C. Urinary retention.
• D. Fever of 102°F.

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

4. Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?

• A. Signs and symptoms of extrapyramidal effects (EPS).
• B. Information about substance abuse and schizophrenia.
• C. The effects of alcohol and drug interaction.
• D. The availability of support groups for those with dual diagnoses.

Correct answer: C

Rationale: Teaching about the effects of alcohol and drug interaction is crucial to prevent adverse reactions, especially with the long-acting injectable form of fluphenazine. Understanding how alcohol and drugs can interact with the medication will help the client and family to ensure medication effectiveness and avoid potential harmful effects. Choices A, B, and D are not the most important to teach in this scenario. While knowing the signs and symptoms of extrapyramidal effects (EPS) is important, understanding the effects of alcohol and drug interaction is more critical in this specific situation. Information about substance abuse and schizophrenia, as well as the availability of support groups, are essential aspects of care but are not the primary focus when switching to a long-acting injectable medication due to non-compliance.

5. How should the RN respond to the mother?

• A. Ask the mother if she has ever thought about harming herself or her child.
• B. Reassure the mother that her child will achieve some growth and development milestones.
• C. Determine if the mother has other children who do not have developmental disabilities.
• D. Encourage the mother to write her thoughts and feelings in a journal.

Correct answer: A

Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.

Similar Questions