a nurse is creating a plan of care for a newly admitted client who has obsessive compulsive disorder which of the following interventions should the n

ATI RN

ATI Comprehensive Exit Exam

1. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

A. Allow the client enough time to perform rituals
B. Give the client autonomy in scheduling activities
C. Discourage the client from exploring irrational fears
D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

2. What is the initial intervention for a patient with chest pain?

A. Administer aspirin
B. Administer nitroglycerin
C. Provide pain relief
D. Prepare for surgery

Correct answer: A

Rationale: The correct initial intervention for a patient with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in case the chest pain is due to a cardiac event. Administering nitroglycerin may follow aspirin administration to help relieve chest pain by dilating blood vessels. Providing pain relief is a general approach and may not address the underlying cause of chest pain. Preparing for surgery would not be the initial intervention for chest pain unless there are specific indications for immediate surgical intervention.

3. A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload?

A. Low back pain
B. Dyspnea
C. Hypotension
D. Thready pulse

Correct answer: B

Rationale: The correct answer is B: Dyspnea. Dyspnea, or difficulty breathing, is a common sign of fluid overload in a client receiving packed RBCs. When fluid accumulates in the lungs due to overload, it can lead to respiratory distress. This finding requires prompt intervention to prevent further complications. Choices A, C, and D are incorrect: A) Low back pain is not typically associated with fluid overload; C) Hypotension refers to low blood pressure and is not a typical finding in fluid overload; D) Thready pulse may indicate poor perfusion but is not a direct indicator of fluid overload.

4. A nurse is caring for a client who has a new prescription for nitroglycerin transdermal patches. Which of the following instructions should the nurse include?

A. Apply the patch to the same location each time.
B. Rotate the patch site daily to avoid skin irritation.
C. Apply the patch in the morning and remove it at bedtime.
D. Keep the patch on at all times, even during a bath.

Correct answer: C

Rationale: The correct answer is to apply the nitroglycerin transdermal patch in the morning and remove it at bedtime. This schedule helps prevent tolerance to the medication. Choice A is incorrect because the patch should be rotated to different sites to prevent skin irritation. Choice B is incorrect as daily rotation is recommended, not daily application to the same site. Choice D is incorrect as the patch should be removed during a bath as it may decrease the efficacy of the medication.

5. What is the best intervention for a patient with dehydration?

A. Administer IV fluids
B. Provide oral fluids
C. Encourage fluid intake
D. Administer electrolytes

Correct answer: A

Rationale: Administering IV fluids is the best intervention for a patient with dehydration because it is the fastest and most effective way to rehydrate the body. IV fluids can quickly restore fluid volume and electrolyte balance in severe cases of dehydration. Providing oral fluids or encouraging fluid intake may not be sufficient for patients with moderate to severe dehydration, as they may have impaired gastrointestinal absorption. While electrolytes are essential for rehydration, administering them alone without fluid replacement may not address the primary issue of fluid loss in dehydration.