Nokea
A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan? (select one that does not apply.)
- A. Compulsions relieve anxiety
- B. Anxiety is the key reason for OCD
- C. Obsessions cause compulsions
- D. Obsessive thoughts are linked to levels of neurochemicals
Correct Answer: C
Rationale: The correct answer is C. Obsessions do not cause compulsions; rather, obsessions are intrusive, unwanted thoughts, images, or urges that trigger intensely distressing feelings, while compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Choices A, B, and D are incorrect. Choice A is incorrect because compulsions are behaviors or mental acts aimed at reducing distress or preventing a dreaded event or situation. Choice B is incorrect because while anxiety is often a significant component of OCD, it is not the only reason for the disorder. Choice D is incorrect because obsessive thoughts are not solely linked to levels of neurochemicals but are more complex and multifactorial.
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A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?
- A. Images indicate the presence of tumors and scars.
- B. The scan clearly outlines structures of the brain.
- C. Results show activity in various portions of the brain.
- D. PET shows biochemical levels of neurotransmitters.
Correct Answer: C
Rationale: The correct answer is C. PET scans are primarily used to detect and observe the metabolic activity in various parts of the brain. This helps in diagnosing conditions related to brain function, such as tumors, brain disorders, and overall brain activity. Choices A, B, and D are incorrect because PET scans focus on metabolic activity and functions in the brain rather than solely indicating the presence of tumors, outlining brain structures, or showing biochemical levels of neurotransmitters.
A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?
- A. Administer prescribed medication to manage symptoms.
- B. Provide a calm environment with minimal stimulation.
- C. Encourage the client to express feelings and emotions.
- D. Reinforce the need for consistent medication adherence.
Correct Answer: A
Rationale: Administering prescribed medication to manage symptoms is the priority intervention for a client with symptoms of mania. During a manic episode, the client may be at risk of harm to self or others due to impulsivity and poor judgment. Medication helps stabilize the client, reduce manic symptoms, and prevent further escalation. Providing a calm environment (choice B) is important but not the priority when the client's safety is at risk. Encouraging expression of feelings (choice C) and reinforcing medication adherence (choice D) are valuable aspects of care but addressing the acute symptoms of mania takes precedence to ensure the client's immediate safety and well-being.
A newly admitted client describes her mission in life as one of saving her son by eliminating the 'provocative sluts' of the world. There are several attractive young women on the unit. What should the LPN/LVN do first?
- A. Ask the client for her definition of 'provocative sluts'
- B. Ask the young female clients on the unit to dress less provocatively
- C. Ask the client to discuss her concerns in the next group session
- D. Ask the client to inform the staff if she has negative thoughts about other clients
Correct Answer: D
Rationale: The correct action for the LPN/LVN to take first is to ask the client to inform the staff if she has negative thoughts about other clients. This approach is crucial as it helps in monitoring the client's thoughts and behaviors, potentially preventing any harmful actions towards others on the unit. Asking for the client's definition of 'provocative sluts' (Choice A) may not address the immediate concern of monitoring the client's harmful thoughts. Asking the young female clients to dress less provocatively (Choice B) is inappropriate and victim-blaming. Asking the client to discuss her concerns in the next group session (Choice C) may not be effective in addressing the potential harm the client's thoughts could pose to others on the unit.
A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?
- A. Claustrophobia.
- B. Acrophobia.
- C. Agoraphobia.
- D. Necrophobia.
Correct Answer: C
Rationale: The correct answer is C, Agoraphobia. Agoraphobia involves the fear of situations where escape might be difficult, often leading to the individual avoiding public spaces or leaving their home. In this case, the client's reluctance to leave home, not going to work, and staying indoors for an extended period align with the symptoms of agoraphobia. Choices A, B, and D are incorrect. Claustrophobia is the fear of confined spaces, acrophobia is the fear of heights, and necrophobia is the fear of death or dead things, none of which are consistent with the client's symptoms described in the scenario.
Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend a daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?
- A. Medication non-compliance.
- B. Number of bathroom facilities.
- C. Infection control.
- D. Acting out behaviors.
Correct Answer: C
Rationale: The priority issue that the RN should address is infection control. The unsanitary conditions in the bathroom, with sputum on the walls, urine in the sink and on the floors, and the toilet clogged with tissue, paper towels, and feces, pose a significant health risk to all residents and staff. Addressing infection control is crucial to prevent the spread of diseases and ensure the well-being of everyone in the facility. Medication non-compliance is important but not the priority in this situation. The number of bathroom facilities, while relevant, is not the immediate concern when faced with unsanitary conditions. Acting out behaviors, though a valid concern in mental health settings, are not the priority when faced with such unsanitary and potentially infectious conditions.