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A newly admitted client diagnosed with obsessive-compulsive disorder (OCD) washes hands continually. This behavior prevents unit activity attendance. Which nursing statement best addresses this situation?
- A. Everyone diagnosed with OCD needs to control their ritualistic behaviors.
- B. It is important for you to discontinue these ritualistic behaviors.
- C. Why are you asking for help if you wont participate in unit therapy?
- D. Lets figure out a way for you to attend unit activities and still wash your hands.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the client's need to wash their hands due to OCD while also addressing the issue of missing unit activities. By suggesting finding a way for the client to attend activities while still accommodating their need to wash hands, it promotes a collaborative approach and respects the client's autonomy. Option A is incorrect as not everyone with OCD can completely control their behaviors. Option B is too directive and may increase resistance. Option C is confrontational and may discourage the client from seeking help.
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Which rationale by a nursing instructor best explains why it is challenging to globally classify the Asian American culture?
- A. Extremes of emotional expression prevent accurate assessment of this culture.
- B. Suspicion of Western civilization has resulted in minimal cultural research.
- C. The small size of this subpopulation makes research virtually impossible.
- D. The Asian American culture includes individuals from many different countries.
Correct Answer: D
Rationale: The correct answer is D because the Asian American culture is not monolithic but comprises individuals from diverse Asian countries with unique customs, languages, and traditions. This diversity makes it challenging to globally classify the culture as a whole. Option A is incorrect as emotional expression varies within Asian American communities. Option B is incorrect as there has been cultural research on Asian Americans. Option C is incorrect as the size of the population does not hinder research efforts.
During the first interview with a man from Syria who has just lost his son in a car accident, in sympathy for the mans loss, the female nurse reaches out and hugs him. Which is an accurate evaluation of the nurses action?
- A. The nurses action should be evaluated as unacceptable due to breech of cultural norms.
- B. The nurses action should be evaluated as empathetic, encouraging expression of feelings.
- C. The nurses action should be evaluated as the technique of offering self.
- D. The nurses action should be evaluated as inappropriate due to poor timing.
Correct Answer: A
Rationale: The correct answer is A because the nurse's action of hugging the man from Syria who just lost his son in a car accident breaches cultural norms. In many Middle Eastern cultures, physical touch, especially between unrelated individuals of the opposite sex, is considered inappropriate and can be seen as disrespectful. This can cause discomfort and may even offend the individual. In this scenario, the nurse should respect the man's cultural background and find alternative ways to show empathy and support, such as verbal expressions of sympathy or offering a comforting presence.
Choice B is incorrect because while the nurse may have intended to show empathy, the method of hugging was culturally inappropriate. Choice C is incorrect as offering self typically involves sharing personal experiences to build rapport, not physical touch. Choice D is also incorrect as the issue lies more with cultural norms rather than poor timing.
What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?
- A. Acknowledge the clients actions and generate alternative behaviors.
- B. Establish rapport and develop treatment goals.
- C. Attempt to find alternative placement.
- D. Explore how thoughts and feelings about this client may adversely impact care.
Correct Answer: B
Rationale: The correct answer is B: Establish rapport and develop treatment goals. During the introductory phase of the nurse-client relationship, establishing rapport is essential to build trust and a therapeutic alliance. Developing treatment goals collaboratively with the client sets the foundation for the care plan. This action promotes client engagement and empowerment. Acknowledging client actions and generating alternative behaviors (A) is more suited for later phases. Attempting to find alternative placement (C) is not appropriate in the introductory phase. Exploring how thoughts and feelings impact care (D) is important but not the priority during the orientation phase.
Which of the following symptoms should a nurse expect to assess in a client experiencing elevated levels of thyroid hormone? Select all that apply.
- A. Emotional lability
- B. Depression
- C. Insomnia
- D. Restlessness
Correct Answer: A
Rationale: The correct answer is A: Emotional lability. Elevated levels of thyroid hormone can lead to increased emotional reactivity and mood swings. This is due to the impact of thyroid hormone on neurotransmitters in the brain. Depression (B) is more commonly associated with low thyroid hormone levels. Insomnia (C) can occur with both high and low thyroid hormone levels. Restlessness (D) is more indicative of hyperthyroidism, where there is excess thyroid hormone.
From an interpersonal theory perspective, which intervention would a nurse use to assist a client diagnosed with major depressive disorder?
- A. Offer family therapy sessions
- B. Discuss childhood events
- C. Teach alternate coping skills
- D. Encourage discussion of feelings
Correct Answer: A
Rationale: The correct answer is A because family therapy sessions can help address underlying family dynamics contributing to the client's depression. This intervention aligns with interpersonal theory, which focuses on improving relationships and communication within the client's social network. Family therapy can enhance support systems and promote healthier interactions.
Option B is incorrect as discussing childhood events may not directly address current interpersonal difficulties. Option C, teaching coping skills, is helpful but may not target the interpersonal issues specific to major depressive disorder. Option D, encouraging discussion of feelings, is important but may not address the broader interpersonal dynamics impacting the client's condition.