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 neonate born at 32 weeks' gestation and weighing 3 lb (1361 g) is admitted to the neonatal intensive care unit (NICU). When would the nurse take the neonate's mother to visit the infant?

• A. When the infant's condition has stabilized
• B. When the infant is out of immediate danger
• C. When the primary health care provider has provided written permission
• D. When the mother is well enough to be taken to the NICU

Correct answer: D

Rationale: The mother should see her infant as soon as possible to acknowledge the reality of the birth and begin bonding. Delaying the visit may impede maternal-infant bonding. The timing of the mother's visit should be based on her physical and emotional readiness, not solely on the infant's condition or the need for written permission. The nurse can independently facilitate the mother's visit without requiring a prescription from the primary healthcare provider.

3. While planning care for a 2-year-old hospitalized child, which situation would the nurse most likely expect to affect the behavior?

• A. Strange bed and surroundings.
• B. Separation from parents.
• C. Presence of other toddlers.
• D. Unfamiliar toys and games.

Correct answer: B

Rationale: The correct answer is 'Separation from parents.' Separation anxiety is most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress. Choices A, C, and D are incorrect because while strange bed and surroundings, presence of other toddlers, and unfamiliar toys and games may contribute to some level of stress or discomfort, the separation from parents is the primary factor affecting the behavior of a 2-year-old hospitalized child.

4. When assessing the mental status of a young school-aged child, which action would be important for the nurse to take?

• A. Listen to the parents' description of the child's behavior.
• B. Compare the child's function from one occasion to another.
• C. Engage the parents in a discussion about the child's feelings.
• D. Determine the child's mental status through direct questioning.

Correct answer: B

Rationale: To accurately assess the mental status of a young school-aged child, it is crucial for the nurse to compare the child's function over time. This approach allows for a more objective evaluation of the child's mental status. While listening to the parents' description of the child's behavior can provide valuable insights, it may be biased and subjective. Engaging parents in discussions about the child's feelings is important for overall understanding but may not directly assess the child's mental status. Directly questioning the child about their mental status can be threatening and may lead to anxiety, making it a less optimal approach compared to observing and comparing the child's function over time.

5. Which type of environment would be most suitable for a confused client?

• A. Familiar
• B. Variable
• C. Challenging
• D. Stimulating

Correct answer: A

Rationale: The most appropriate environment for a confused client is a familiar one. A familiar environment provides security and safety, reducing stress for the confused client. Confused individuals struggle to adapt to constant changes, making a variable environment unsuitable. A challenging environment would likely increase anxiety and frustration in a confused client. Similarly, a stimulating environment could overwhelm the confused client, exacerbating their confusion.

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