Nursing Elites

1. What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?

• A. Discussing the repetitive actions.
• B. Insisting the client not perform the repetitive act.
• C. Informing the client that the act is not necessary.
• D. Encouraging daily exercise.

Correct answer: D

Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.

2. If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?

• A. Document the finding
• B. Send a specimen to the lab
• C. Strain the dialysate
• D. Obtain a complete blood count

Correct answer: B

Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.

3. A 6-month-old client is admitted with possible intussusception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?

• A. "Tell me about his pain."?
• B. "What does his vomit look like?"?
• C. "Describe his usual diet."?
• D. "Have you noticed changes in his abdominal size?"?

Correct answer: C

Rationale: The least helpful question in obtaining information regarding intussusception is "Describe his usual diet."? This question is least relevant to the specific symptoms and presentation of intussusception. Choices A, B, and D are more directly related to symptoms commonly associated with intussusception and can provide important diagnostic clues. Asking about pain, vomit appearance, and changes in abdominal size can help in assessing the severity and progression of the condition, making them more crucial questions to ask in this scenario. Pain is a cardinal symptom of intussusception, changes in vomit appearance may indicate gastrointestinal issues, and alterations in abdominal size can signify the presence of a mass or obstruction, all of which are pertinent in diagnosing and managing intussusception.

4. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:

• A. conversion.
• B. regression
• C. introjection.
• D. rationalization

Correct answer: B

Rationale: Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Regression involves reverting to an earlier stage of development to cope with stress or conflict. In this scenario, the nurse regressed to a childlike state by crying when faced with the disappointment of not getting the promotion, demonstrating regression as a defense mechanism. Conversion involves transforming anxiety into a physical symptom. Introjection involves unconsciously identifying intensely with another person. Rationalization involves unconsciously creating acceptable explanations to justify unacceptable ideas, actions, or feelings. Therefore, the correct answer is regression as it aligns with the nurse's behavior of regressing to a childlike state by crying due to the disappointment of not receiving the promotion.

5. While the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated?

• A. Hemoglobin
• B. Creatinine
• C. Blood glucose
• D. White blood cell count

Correct answer: C

Rationale: When a client is receiving total parenteral nutrition (TPN), monitoring blood glucose levels is crucial as TPN solutions contain high amounts of glucose. This monitoring helps prevent hyperglycemia or hypoglycemia. Evaluating hemoglobin (choice A) is not directly related to TPN administration. Creatinine (choice B) is more relevant for assessing kidney function. White blood cell count (choice D) is important for evaluating immune function and infection, but not specifically tied to TPN administration.

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