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A patient with obsessive-compulsive disorder (OCD) spends hours washing their hands. Which nursing intervention is most appropriate?
- A. Encouraging the patient to stop washing their hands
- B. Allowing the patient to wash hands at specified times
- C. Ignoring the patient's behavior
- D. Setting strict limits on the time allowed for hand washing
Correct Answer: B
Rationale: The correct answer is B: Allowing the patient to wash hands at specified times. This option acknowledges the patient's need for hand washing while also setting boundaries. By allowing the patient to wash hands at specified times, the nurse can help establish a routine and gradually reduce the excessive hand washing behavior. Encouraging the patient to stop washing hands (A) may increase anxiety and resistance. Ignoring the behavior (C) can reinforce it. Setting strict limits (D) may cause distress and worsen the OCD symptoms. Option B strikes a balance between addressing the patient's needs and promoting healthier behaviors.
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A patient with obsessive-compulsive disorder (OCD) performs hand washing repeatedly. Which nursing intervention is most appropriate?
- A. Restricting the patient from washing hands
- B. Setting strict limits on the patient's hand washing
- C. Allowing the patient to wash hands at specified times
- D. Ignoring the patient's behavior
Correct Answer: C
Rationale: The most appropriate nursing intervention for a patient with OCD who performs hand washing repeatedly is to allow the patient to wash hands at specified times (Choice C). This approach promotes a balance between addressing the patient's need for cleanliness and preventing excessive hand washing. By allowing the patient to wash hands at specific times, the nurse can help establish a routine that provides a sense of control for the patient while also setting boundaries to prevent excessive behavior. Restricting the patient from washing hands (Choice A) can lead to increased anxiety and resistance. Setting strict limits on hand washing (Choice B) may also trigger anxiety and escalate the behavior. Ignoring the patient's behavior (Choice D) does not address the underlying issue and can lead to worsening symptoms. Ultimately, Choice C supports a therapeutic approach that acknowledges the patient's needs while promoting healthier coping strategies.
A healthcare professional is assessing a patient with bipolar disorder. Which finding suggests the patient is experiencing a manic episode?
- A. Decreased need for sleep
- B. Feelings of worthlessness
- C. Increased need for sleep
- D. Avoidance of social interactions
Correct Answer: A
Rationale: The correct answer is A: Decreased need for sleep. During a manic episode in bipolar disorder, individuals often experience decreased need for sleep. This is a key symptom of mania, as it is characterized by high energy levels, impulsivity, and decreased need for rest. In contrast, option B (feelings of worthlessness) is more reflective of symptoms seen in depressive episodes, not manic episodes. Option C (increased need for sleep) is also not indicative of mania, as mania is associated with decreased sleep. Option D (avoidance of social interactions) may occur in some cases, but it is not a defining feature of mania.
When a patient is diagnosed with major depressive disorder, which nursing diagnosis should be the priority?
- A. Imbalanced nutrition: less than body requirements
- B. Risk for suicide
- C. Disturbed sleep pattern
- D. Ineffective coping
Correct Answer: B
Rationale: The correct answer is B: Risk for suicide. This is the priority nursing diagnosis because individuals with major depressive disorder have an increased risk of suicidal ideation and behaviors. Assessing and addressing this risk is crucial for patient safety. Choice A is not the priority as nutritional imbalances may not pose immediate harm compared to suicide risk. Choice C, disturbed sleep pattern, and choice D, ineffective coping, are important but not as critical as addressing the risk of suicide in a patient with major depressive disorder.
While being treated in an inpatient facility, what is the most appropriate intervention for a patient with anorexia nervosa?
- A. Allowing the patient to eat alone to reduce stress
- B. Monitoring the patient's weight daily
- C. Encouraging the patient to exercise daily
- D. Providing the patient with a high-calorie diet
Correct Answer: B
Rationale: The correct answer is B: Monitoring the patient's weight daily. This intervention is crucial in managing anorexia nervosa as it helps track the patient's progress and identify any concerning weight fluctuations promptly. Daily weight monitoring allows healthcare providers to adjust treatment plans accordingly and ensure the patient's safety.
Choice A: Allowing the patient to eat alone to reduce stress is incorrect because isolation during meals can exacerbate the patient's disordered eating behaviors and hinder the recovery process.
Choice C: Encouraging the patient to exercise daily is incorrect as excessive exercise is a common symptom of anorexia nervosa and can further contribute to the patient's physical and psychological health risks.
Choice D: Providing the patient with a high-calorie diet is incorrect without proper monitoring as it can lead to refeeding syndrome and other complications. Monitoring the patient's weight is essential before implementing dietary changes.
Which therapeutic communication technique is being used when the nurse says, 'Tell me more about what you are feeling right now'?
- A. Restating
- B. Clarification
- C. Reflection
- D. Exploration
Correct Answer: D
Rationale: The correct answer is D: Exploration. This therapeutic communication technique encourages the patient to expand on their feelings, promoting exploration of thoughts and emotions. By asking the patient to elaborate on their feelings, the nurse facilitates deeper understanding. Restating (A) involves repeating the patient's words back to them. Clarification (B) is seeking to understand the patient's meaning. Reflection (C) involves mirroring the patient's emotions. In this scenario, the nurse is prompting the patient to delve further into their emotions, making exploration the most appropriate technique.