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A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Schedule specific times for handwashing.
- C. Encourage the client to discuss the thoughts and feelings behind the behavior.
- D. Restrict the client's access to soap and water.
Correct Answer: C
Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.
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A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?
- A. Encourage the client to ignore the voices.
- B. Tell the client that the voices will go away with medication.
- C. Monitor the client for signs of self-harm.
- D. Refer the client for a psychiatric evaluation.
Correct Answer: D
Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.
During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the nurse respond?
- A. Anger is contagious and could result in major confrontation.
- B. Try not to let your anger cause you to act impulsively.
- C. Expressing your anger to a stranger could result in an unsafe situation.
- D. It sounds as if you feel angry for no reason
Correct Answer: C
Rationale: The correct responses are C and D. The nurse should acknowledge the employee's feelings of anger and suggest that expressing anger to strangers, like other drivers, could lead to unsafe situations. This response aims to prevent potential confrontations or harm. Choice A is incorrect as it doesn't address the specific situation of expressing anger while driving. Choice B is also incorrect as it is vague and doesn't provide practical advice to manage the anger effectively.
A female client with borderline personality disorder expresses fear of being abandoned by the nursing staff. What is the best nursing intervention?
- A. Reassure the client that she will not be abandoned.
- B. Set limits on the client's behavior and enforce them consistently.
- C. Encourage the client to talk about her fears.
- D. Rotate the nursing staff assigned to the client frequently.
Correct Answer: B
Rationale: The best nursing intervention for a client with borderline personality disorder expressing fear of abandonment is to set limits on the client's behavior and enforce them consistently. This approach helps establish boundaries and provides a sense of security for the client. Choice A may provide temporary reassurance but does not address the core issue or help the client develop coping strategies. Choice C is important but should be accompanied by setting limits to address the underlying fear of abandonment. Choice D of rotating staff frequently can exacerbate the client's fear of abandonment by reinforcing the idea of being left.
During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?
- A. Encourage the client to participate in a quiet activity.
- B. Provide a safe environment and limit stimuli.
- C. Administer a sedative to help the client sleep.
- D. Discuss the consequences of her risky behaviors.
Correct Answer: B
Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.
A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?
- A. Mood swings.
- B. Extreme sadness.
- C. Manipulative behavior.
- D. Flat affect.
Correct Answer: D
Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.