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A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?
- A. Ask the client for permission to take photographs.
- B. Document the client's verbatim statements.
- C. Provide community sexual assault support contacts.
- D. Determine any physical signs of injury.
Correct Answer: D
Rationale: The correct answer is D: Determine any physical signs of injury. This should be the first action taken by the nurse in this situation because assessing for physical signs of injury is crucial for ensuring the client's immediate safety and well-being. By assessing for physical injuries, the nurse can prioritize medical treatment if needed and gather important forensic evidence. This initial assessment also helps in determining the urgency of the situation and guides the next steps in providing appropriate care and support.
Choices A, B, and C are incorrect as they are not the priority in this situation. Asking for permission to take photographs, documenting verbatim statements, and providing community sexual assault support contacts are important actions but should come after ensuring the client's immediate physical well-being is addressed. It is essential to focus on the client's physical safety and health first before moving on to other aspects of care and support.
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A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.
A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)
- A. Difficulty relaxing
- B. Irrational fear of certain objects
- C. Rule-conscious behavior
- D. Unaware of compulsions
- E. Perfectionist behavior
Correct Answer: A, B, C, E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Difficulty relaxing is an expected finding in OCD due to persistent intrusive thoughts causing anxiety and tension.
B: Irrational fear of certain objects is common in OCD, leading to compulsive behaviors to reduce anxiety.
C: Rule-conscious behavior is a characteristic of OCD where individuals feel compelled to follow specific routines or rules.
E: Perfectionist behavior is a common trait in OCD as individuals strive for perfection to alleviate anxiety.
Incorrect Choices:
D: Individuals with OCD are usually aware of their compulsions, distinguishing them from other disorders.
F, G: No additional choices provided.
Summary:
The correct answers (A, B, C, E) align with the typical symptoms of OCD, including anxiety, compulsions, rule-following, and perfectionism. The incorrect choices (D, F, G) do not accurately reflect the expected findings in OCD.
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?
- A. Watching a video with a group in the day room
- B. Walking with the nurse in the courtyard
- C. Participating in a basketball game in the gym
- D. Joining a group discussion about a local election
Correct Answer: B
Rationale: The correct answer is B: Walking with the nurse in the courtyard. During the manic phase, individuals with bipolar disorder may have high energy levels and increased impulsivity. Walking in the courtyard with the nurse provides a safe outlet for physical activity and helps to channel excess energy in a constructive manner. This activity also allows for one-on-one interaction, which can help the client focus and reduce boredom. Other options like watching a video with a group or participating in a basketball game may be too stimulating and could exacerbate manic symptoms. Joining a group discussion about a local election might be overwhelming and less effective in managing the client's energy level and attention.
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Affective flattening.
- B. Bizarre behavior.
- C. Illogicality.
- D. Somatic delusions.
Correct Answer: A
Rationale: The correct answer is A: Affective flattening. Negative symptoms in schizophrenia refer to deficits in normal emotional responses or behaviors. Affective flattening specifically involves a reduction in the expression of emotions, such as reduced facial expressions and tone of voice. This is a core negative symptom in schizophrenia. Bizarre behavior (choice B) is associated with positive symptoms, such as hallucinations and delusions. Illogicality (choice C) is a cognitive symptom related to disorganized thinking. Somatic delusions (choice D) are also positive symptoms involving false beliefs about the body. By process of elimination, Affective flattening is the correct answer.
A nurse is caring for a client who has schizophrenia who consistently does the opposite of what the nurse asks of him. The nurse recognizes this as which of the following alterations in behavior?
- A. Automatic obedience
- B. Waxy flexibility
- C. Negativism
- D. Impaired impulse control
Correct Answer: C
Rationale: The correct answer is C: Negativism. Negativism is a behavior where the client does the opposite of what is asked or expected. In this case, the client with schizophrenia consistently does the opposite of what the nurse asks, which aligns with negativism. Automatic obedience (A) is when a client complies without question, waxy flexibility (B) is characterized by maintaining limbs in the position they are placed in, and impaired impulse control (D) involves difficulty controlling impulses, none of which fit the scenario described.