Nursing Elites

1. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

• A. Anxiety
• B. Hostility
• C. Aggression
• D. Withdrawal

Correct answer: A

Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.

2. A new mother with class II heart disease tells the nurse that she is afraid her heart condition will prevent her from caring for her baby at home when she is discharged. How would the nurse respond?

• A. Suggest that the client arrange for help at home
• B. Ask the client to describe her concerns more fully
• C. Tell the client to speak to her primary health care provider about her concerns
• D. Recommend that the client schedule times when family members can assist her

Correct answer: B

Rationale: When a client expresses fear or concern, it is essential for the nurse to first explore and understand the client's feelings and worries. Asking the client to describe her concerns more fully allows the nurse to gather more information, which is crucial in providing appropriate support and guidance. Suggesting that the client arrange for help at home is presumptuous and may not align with the client's preferences or resources. Telling the client to speak to her primary health care provider shifts the responsibility and does not directly address the client's immediate fears. Recommending that she schedule times when family members can assist her assumes the availability and willingness of family members without addressing the client's emotional needs and fears directly.

3. A client arrives at an occupational health clinic after being struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?

• A. Pulse characteristics
• B. Open airway
• C. Entrance and exit wounds
• D. Cervical spine injury

Correct answer: A

Rationale: Assessing pulse characteristics is the priority in this situation due to the potential impact of lightning as a form of electrical current, which can cause irregular heart rhythms. It is crucial to evaluate the pulse rate and regularity to assess for adequate circulation and potential cardiac issues. Since the client is alert and talking, the airway is likely patent, making assessing the airway less urgent. Entrance and exit wounds and cervical spine injury assessments should follow the evaluation of pulse characteristics to ensure proper circulation and prioritize life-threatening issues first. Checking the pulse first will guide further interventions and help in determining the client's hemodynamic status.

4. Which response would the nurse make when a client moans softly, 'Oh no, I'm next. They couldn't protect him, and they can't protect me,' after learning a recently discharged client committed suicide?

• A. ''The other person was a lot sicker than you are.''
• B. 'You seem to be afraid that you'll hurt yourself.''
• C. 'That was different. He was at home, but you're here.''
• D. 'There's no need to worry. You have a better support system.''

Correct answer: B

Rationale: The nurse would make the statement, 'You seem to be afraid that you'll hurt yourself.' This response acknowledges the client's emotional distress and opens up the opportunity for the client to discuss their feelings, showing empathy and understanding. Choice A, 'The other person was a lot sicker than you are,' dismisses the client's emotions and fails to address the underlying fear of self-harm. Choice C, 'That was different. He was at home, but you're here,' invalidates the client's concerns and does not encourage further discussion. Choice D, 'There's no need to worry. You have a better support system,' offers false reassurance and does not address the client's expressed fear, missing an opportunity for therapeutic communication.

5. Which factor is most critical for a single mother of 2 children who recently lost her job and does not know what to do?

• A. Developmental history of children
• B. Available situational supports
• C. Underlying unconscious conflict
• D. Willingness to restructure lifestyle

Correct answer: B

Rationale: In a crisis intervention, the priority is to identify available situational supports, such as family, friends, community resources, and social services, that can help the single mother and her children during this difficult time. Understanding the developmental history of the children may be important to assess their needs, but it is not the most critical factor in this immediate crisis. Exploring underlying unconscious conflicts is more suited for long-term therapy rather than crisis intervention. While the willingness to restructure lifestyle may eventually be necessary, the immediate focus should be on finding support systems to address the current crisis.

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