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A client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: The correct answer is A: Set a specific limit on the number of times the client can check the door. This intervention helps establish boundaries and structure for the client, which can assist in reducing compulsive behaviors. By setting a specific limit, the client is encouraged to gradually decrease the checking behavior and learn to cope with the anxiety associated with uncertainty. This approach promotes independence and empowerment for the client.
Choice B is incorrect because finding an alternative activity does not directly address the obsessive checking behavior. Choice C is incorrect as providing consistent reassurance reinforces the compulsive behavior. Choice D is incorrect because ignoring the behavior does not actively address or help decrease the compulsive checking.
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When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Ensuring the client has a patent airway and adequate breathing is crucial for immediate stabilization and preventing further complications. Impaired comfort (choice A) may be a concern but is secondary to ensuring the client can breathe. Risk for injury (choice B) is important but not as immediate as addressing breathing. Ineffective coping (choice D) is important for long-term recovery but addressing the client's breathing takes precedence in this acute situation.
You have been working closely with a patient for the past month. Today he tells you he is looking forward to meeting with his new psychiatrist but frowns and avoids eye contact while reporting this to you. Which of the following responses would most likely be therapeutic?
- A. A new psychiatrist is a chance to start fresh; I’m sure it will go well for you.
- B. You say you look forward to the meeting, but you appear anxious or unhappy.
- C. I notice that you frowned and avoided eye contact just now. Don’t you feel well?
- D. I get the impression you don’t really want to see your psychiatrist—can you tell me why?
Correct Answer: B
Rationale: The correct answer is B. This response acknowledges the patient's non-verbal cues and reflects back to the patient what you observed, showing empathy and understanding. It validates the patient's emotions and opens up the opportunity for the patient to further elaborate on their feelings. Choice A minimizes the patient's feelings and may come off as dismissive. Choice C puts the patient on the spot and may make them defensive. Choice D makes an assumption about the patient's feelings without giving them a chance to express themselves.
The nurse is using the CAGE questionnaires as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?
- A. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- B. Minimizes drinking frequently misses family events, guilt about drinking, and amount of daily intake.
- C. Cancer screening results, anger, gastritis, daily alcohol intake.
- D. Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener”.
Correct Answer: D
Rationale: The correct answer is D. The CAGE questionnaire is a screening tool used to identify alcohol abuse. Each letter in CAGE stands for a key question: "Cut down," "Annoyed by criticism," "Guilty feelings," and "Eye-opener." These questions help assess the client's alcohol-related behaviors and attitudes. Exploring the client's efforts to cut down on drinking indicates acknowledgment of a potential issue. Annoyance with questions may suggest defensiveness or denial. Feelings of guilt can indicate internal conflict about drinking, and using alcohol as an "Eye-opener" can signal dependence. Therefore, delving into these specific areas can provide valuable insights into the client's alcohol use patterns and potential problems. Choices A, B, and C are incorrect as they do not align with the purpose of the CAGE questionnaire in identifying alcohol abuse behaviors and attitudes.
The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing?
- A. Provide detailed thorough explanations when cleansing wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask in a non-threatening manner why the client cut own abdomen.
- D. Request another staff member assist with the dressing change.
Correct Answer: B
Rationale: The correct answer is B: Perform the dressing change in a non-judgmental manner. When caring for a client with borderline personality disorder who has self-inflicted injuries, it is crucial to approach the situation with empathy and without passing judgment. This approach helps build trust, maintains the therapeutic relationship, and encourages open communication. Providing detailed explanations (choice A) may overwhelm the client. Asking about the self-inflicted behavior (choice C) in a non-threatening manner can be appropriate but should not be the primary focus during the dressing change. Requesting another staff member's assistance (choice D) may not be necessary if the RN can handle the situation effectively.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Encourage the client to exercise.
- B. Suggest that the client develop a list of pleasurable activities.
- C. Provide education on methods to enhance sleep.
- D. Teach the client to develop a plan for daily structured activities.
Correct Answer: D
Rationale: The correct answer is D: Teach the client to develop a plan for daily structured activities. This intervention is most effective because it addresses the symptoms presented by the client - psychomotor retardation, hypersomnia, and amotivation. Structured activities can help regulate the client's daily routine, combat inertia, and provide a sense of purpose and accomplishment. By setting specific tasks and goals, the client can gradually increase their level of activity and engagement, which can improve mood and motivation. Encouraging exercise (choice A) may be beneficial, but developing a structured plan encompasses a broader approach to address all symptoms. Creating a list of pleasurable activities (choice B) may not address the lack of motivation or structure. Providing education on sleep enhancement methods (choice C) may not directly address psychomotor retardation and amotivation.