Nursing Elites

1. A client is being treated for obsessive-compulsive disorder (OCD). Which intervention should be included in the care plan?

• A. Discourage the client from performing rituals.
• B. Allow the client to perform rituals in the early stages of treatment.
• C. Encourage the client to focus on their compulsions.
• D. Isolate the client to prevent performance of rituals.

Correct answer: B

Rationale: Allowing the client to perform rituals in the early stages of treatment is a common therapeutic approach for obsessive-compulsive disorder (OCD). Allowing the client to engage in rituals can help reduce anxiety by providing temporary relief. It is a part of exposure therapy, where the individual is gradually exposed to anxiety-provoking situations. As treatment progresses, the focus shifts to gradually reducing the frequency and intensity of rituals through interventions like exposure and response prevention therapy. Discouraging the client from performing rituals (Choice A) is not recommended as it may increase anxiety and resistance to treatment. Encouraging the client to focus on their compulsions (Choice C) may reinforce the behavior rather than helping to decrease it. Isolating the client (Choice D) is not therapeutic and can lead to feelings of abandonment and worsen symptoms.

2. Which is an example of the ego defense mechanism of regression?

• A. A mother blames the teacher for her child's failure in school.
• B. A teenager becomes hysterical after seeing a friend killed in a car accident.
• C. A woman wants to marry a man exactly like her beloved father.
• D. An adult throws a temper tantrum when he does not get his own way.

Correct answer: D

Rationale: The correct answer is D. Regression involves reverting to an earlier stage of development for comfort. In this case, an adult throwing a temper tantrum is regressing to a childlike behavior when faced with not getting their way, which is a form of seeking comfort associated with earlier development. Choices A, B, and C do not exemplify regression. Blaming the teacher, becoming hysterical after a traumatic event, or seeking a partner similar to a beloved father are not instances of reverting to earlier developmental stages to cope with stress or conflict.

3. During an assessment of a client with suspected substance use disorder, which of the following findings should the nurse expect? Select one that doesn't apply.

• A. Feelings of hopelessness
• B. Increased tolerance to the substance
• C. Withdrawal symptoms when not using the substance
• D. Unsuccessful attempts to cut down or control use

Correct answer: A

Rationale: In clients with substance use disorder, common findings include increased tolerance to the substance, withdrawal symptoms when not using it, and unsuccessful attempts to cut down or control use. Feelings of hopelessness are not typically a direct manifestation of substance use disorder. Instead, feelings of hopelessness may be associated with other mental health conditions or situational factors. Therefore, the correct answer is A. Choices B, C, and D are all expected findings in clients with substance use disorder.

4. A client with obsessive-compulsive disorder (OCD) spends hours each day washing her hands. Which intervention should the nurse implement to help the client reduce this behavior?

• A. Encourage the client to set a time limit for washing hands.
• B. Encourage the client to wash hands only when necessary.
• C. Encourage the client to use hand sanitizer instead of washing.
• D. Encourage the client to explore the reasons behind the hand washing.

Correct answer: A

Rationale: Setting a time limit for hand washing is an effective intervention in managing obsessive-compulsive disorder (OCD) symptoms. By establishing boundaries around the behavior, the client can gradually work towards reducing the excessive hand washing and regaining control over the compulsion. Choice B is not as effective because it does not address the underlying compulsion. Choice C may not be helpful as it may not satisfy the client's need for cleanliness and could reinforce the behavior. Choice D, while important in therapy, may not be the most immediate intervention needed to address the excessive hand washing behavior.

5. In assessing a patient for signs of serotonin syndrome, which of the following symptoms would be consistent with this condition?

• A. Hypotension, bradycardia, hypothermia
• B. Hypertension, tachycardia, hyperthermia
• C. Hypotension, tachycardia, hypothermia
• D. Hypertension, bradycardia, hyperthermia

Correct answer: B

Rationale: Serotonin syndrome is characterized by a triad of symptoms: hypertension, tachycardia, and hyperthermia. Therefore, the correct answer is B. Hypotension, bradycardia, and hypothermia (choice A) are not typical findings in serotonin syndrome. Hypotension, tachycardia, and hypothermia (choice C) are also not consistent with serotonin syndrome. Hypertension, bradycardia, and hyperthermia (choice D) do not align with the characteristic symptoms of serotonin syndrome. Recognizing the key symptoms of serotonin syndrome is crucial for prompt identification and intervention to prevent serious complications.

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