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A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse’s priority response?
- A. "Do you really think your family would be better off without you?"
- B. "Tell me what is happening right now."
- C. "Have you thought of harming yourself?"
- D. "When did you first start feeling this way?"
Correct Answer: C
Rationale: The correct answer is C: "Have you thought of harming yourself?" because it addresses the immediate safety concern of suicidal ideation. It is crucial to assess the client's risk of self-harm or suicide first. Choice A is not a direct inquiry about self-harm. Choice B focuses on the current situation but does not address the suicidal statement. Choice D is more about exploring the history of depressive symptoms rather than assessing immediate risk.
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A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
- A. Difficulty relaxing
- B. Irrational fear of certain objects
- C. Rule-conscious behavior
- D. Unaware of compulsions
- E. Perfectionist behavior
Correct Answer: A, B, C, E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Difficulty relaxing is an expected finding in OCD due to persistent intrusive thoughts causing anxiety and tension.
B: Irrational fear of certain objects is common in OCD, leading to compulsive behaviors to reduce anxiety.
C: Rule-conscious behavior is a characteristic of OCD where individuals feel compelled to follow specific routines or rules.
E: Perfectionist behavior is a common trait in OCD as individuals strive for perfection to alleviate anxiety.
Incorrect Choices:
D: Individuals with OCD are usually aware of their compulsions, distinguishing them from other disorders.
F, G: No additional choices provided.
Summary:
The correct answers (A, B, C, E) align with the typical symptoms of OCD, including anxiety, compulsions, rule-following, and perfectionism. The incorrect choices (D, F, G) do not accurately reflect the expected findings in OCD.
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
- A. Decrease anxiety
- B. Prevent aggressive and impulsive behaviors
- C. Manipulate others
- D. Decrease the time available for interaction with people
Correct Answer: A
Rationale: The correct answer is A: Decrease anxiety. The repetitive cleaning behavior in OCD is a manifestation of the client's attempt to reduce anxiety caused by intrusive thoughts or obsessions. This behavior provides temporary relief from anxiety by creating a sense of control. Choice B is incorrect because OCD cleaning behaviors are not primarily aimed at preventing aggressive or impulsive behaviors. Choice C is incorrect as the cleaning behavior is not typically a form of manipulation. Choice D is incorrect as the primary goal of the behavior is not to decrease interaction time but to manage anxiety.
A nurse is teaching staff which factors to include in an abuse assessment of a client. Which of the following factors should the nurse include in the teaching? (Select all that apply.)
- A. Suicide risk
- B. Socioeconomic status
- C. Coping patterns
- D. Support systems
- E. Alcohol use
Correct Answer: A, C, D, E
Rationale: Suicide risk, coping patterns, support systems, and alcohol use are important considerations in abuse assessments. Socioeconomic status is not always a direct indicator.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.