Nokea
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.
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A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse take first?
- A. Implement seizure precautions.
- B. Insert an IV access site.
- C. Obtain a blood specimen.
Correct Answer: A
Rationale: The correct answer is A: Implement seizure precautions. The priority in caring for a client experiencing acute alcohol withdrawal is to prevent potential life-threatening complications like seizures. Implementing seizure precautions involves ensuring a safe environment, such as padding the bed and removing any harmful objects. This step takes precedence over inserting an IV access site (B) or obtaining a blood specimen (C) because seizures pose an immediate risk to the client's safety. It is crucial to address the most urgent need first to ensure the client's well-being.
A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. "The courts might require me to discuss confidential information."
- B. "I am required to provide confidential information to insurance companies."
- C. "If questioned during a police investigation, I am required to divulge confidential information."
- D. "I am legally allowed to discuss confidential information with the client's former therapist."
Correct Answer: A
Rationale: Confidentiality may be broken if required by law, such as with a court order.
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
A home health nurse is speaking to a group of acute care nurses about domestic violence. Which of the following statements by one of the acute care nurses indicates a need for clarification?
- A. "I have heard that abusers try to keep their partner isolated from others."
- B. "I know that abusers lack social supports and social skills."
- C. "I know that men who are abusers gain power through intimidation."
- D. "I have heard that abusers think of themselves as important and have high self-esteem."
Correct Answer: D
Rationale: Answer D indicates a need for clarification because it presents a misconception about abusers. Abusers typically have low self-esteem and use power and control to compensate. This statement falsely suggests that abusers have high self-esteem and view themselves as important. This misunderstanding could lead to overlooking warning signs and risks associated with domestic violence. It's crucial for healthcare professionals to recognize the true dynamics of abusive relationships to provide appropriate support and interventions. Other choices (A, B, C) align with common knowledge about domestic violence, highlighting the tactics and behaviors typically associated with abusers.
A nurse is caring for a client who has anorexia nervosa and overexercises to avoid gaining weight. Which of the following nursing actions should the nurse take?
- A. Praise the client for looking at herself in a mirror.
- B. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise.
- C. Reprimand the client about the potential damage that has occurred due to overexercising.
- D. Restrict the client from being weighed.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Asking the client to agree to talk to a nurse whenever she feels the urge to exercise is the most appropriate action. This approach promotes open communication and allows for timely intervention to address the client's excessive exercise behavior. It also demonstrates empathy and support, which are crucial in managing anorexia nervosa. By creating a safe space for the client to express her feelings, the nurse can help prevent further harm caused by overexercising.
Summary of other choices:
A: Praising the client for looking at herself in a mirror may reinforce distorted body image perceptions and unhealthy behaviors.
C: Reprimanding the client could lead to feelings of guilt and shame, exacerbating the client's condition.
D: Restricting the client from being weighed may not address the underlying issue of overexercising and can contribute to feelings of lack of control.