Nokea
A newly admitted client with obsessive-compulsive disorder (OCD) is performing ritualistic behaviors. What should the nurse do first?
- A. Discuss alternative coping strategies
- B. Identify precipitating factors for rituals
- C. Instruct on relaxation techniques
- D. Provide a structured activity schedule
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for rituals. This is the first step because understanding what triggers the client's rituals is crucial in developing an effective treatment plan. By identifying these factors, the nurse can address the root cause of the behavior and work towards reducing or eliminating it. Discussing coping strategies (A) may come later once the triggers are identified. Instructing on relaxation techniques (C) and providing a structured activity schedule (D) are helpful interventions but addressing the triggers takes precedence.
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A nurse is speaking with a client experiencing anxiety. Which of the following responses is most therapeutic?
- A. "Most clients with anxiety benefit from lying down."
- B. "Come with me to an area where we can talk without interruption."
- C. "Providers usually recommend relaxation exercises for clients who are upset."
- D. "An antianxiety pill works best for situations like this."
Correct Answer: B
Rationale: The correct answer is B. Bringing the client to an area for uninterrupted conversation shows active listening and support. It promotes a safe space for the client to express feelings and reduces anxiety. Choice A is incorrect as it assumes all clients benefit from lying down, which may not be true. Choice C is incorrect because recommending relaxation exercises may not address the client's immediate needs. Choice D is incorrect as medication should not be the first response for managing anxiety without exploring other options first.
A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
- A. "Your husband is making really good progress."
- B. "Crying helps us let things out and we feel better."
- C. "Did your husband say something to upset you?"
- D. "Tell me what’s concerning you."
Correct Answer: D
Rationale: Encouraging the spouse to verbalize concerns supports therapeutic communication.
A client becomes very dejected and states, "No one really cares what happens to me. Life isn't worth living anymore." Which of the following responses should the nurse make?
- A. "Of course people care. Your family comes to visit every day."
- B. "Tell me who you think doesn't care about you."
- C. "Why do you feel that way?"
- D. "I care about you, and I am concerned that you feel so sad."
Correct Answer: D
Rationale: The correct answer is D because it shows empathy and acknowledges the client's feelings while also expressing concern. It validates the client's emotions and offers support without dismissing or invalidating their experience. Choice A is incorrect as it focuses on the family's visits, which may not address the client's underlying emotional distress. Choice B puts the client on the spot and may come off as confrontational. Choice C is open-ended but lacks the immediate reassurance and support the client needs.
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 conducting a group therapy session for several clients. The group is laughing at a joke one of the clients told, when a client who is schizophrenic jumps up and runs out of the room yelling, "You are all making fun of me!" The nurse should identify this behavior as which of the following characteristics of schizophrenia?
- A. Magical thinking
- B. Delusions of grandeur
- C. Ideas of reference
- D. Looseness of association
Correct Answer: C
Rationale: The correct answer is C: Ideas of reference. This behavior is indicative of ideas of reference, a common symptom of schizophrenia where individuals believe that neutral events or comments are directed at them personally. In this case, the client's perception of laughter at a joke led them to believe it was directed towards them, triggering a paranoid reaction. This is different from magical thinking (A) which involves belief in unrealistic events, delusions of grandeur (B) which involves exaggerated beliefs in one's importance, and looseness of association (D) which is characterized by disconnected thoughts. The other choices are not relevant to the scenario provided.