Nokea
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.
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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
- A. Protecting the client from injury.
- B. Determining the cause of the client’s anxiety.
- C. Ensuring that the client feels safe.
- D. Identifying the client’s coping skills.
Correct Answer: A
Rationale: The correct answer is A: Protecting the client from injury. This is the highest priority because ensuring the client's physical safety takes precedence in a crisis situation. If the client is at risk of harming themselves or others, immediate action must be taken to prevent injury. Determining the cause of anxiety, ensuring the client feels safe, and identifying coping skills are important but secondary priorities once the client's safety is assured. In a crisis situation, physical safety is paramount before addressing underlying causes or providing emotional support.
A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control method the nurse would recommend. Which of the following responses should the nurse make?
- A. "It's your choice, of course, but birth control pills are the most reliable."
- B. "I'd consider an intrauterine device. You won't have to worry about pregnancy."
- C. "Your provider usually recommends a diaphragm and spermicidal cream."
- D. "Let's talk about the available options and go from there."
Correct Answer: D
Rationale: The correct answer is D because it promotes patient-centered care by involving the client in decision-making. The nurse should discuss available birth control options with the client to ensure the method aligns with her preferences, lifestyle, and medical history. This approach empowers the client to make an informed decision that best suits her needs.
Option A is incorrect because it assumes the client's preference without exploring other options. Option B may not align with the client's preferences, and the nurse should not impose a specific method. Option C assumes the provider's recommendation without considering the client's preferences. These options do not prioritize shared decision-making and individualized care.
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?
- A. The client is a danger to herself or others.
- B. The client is unwilling to accept that treatment is needed.
- C. The client states that she does not like the neighbor.
- D. The client states that she plans to move out of the state immediately.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse can keep the client in the hospital after the 72-hour hold if the client is deemed a danger to herself or others. This is crucial in ensuring the safety of the client and others. It indicates that the client poses a significant risk of harm, warranting further evaluation and treatment.
Incorrect Choices:
B: The client's willingness to accept treatment is important, but it does not solely determine if the client can be kept in the hospital.
C: Personal preferences or dislikes are not sufficient reasons to detain a client after the hold is over.
D: Planning to move out of the state does not address the immediate safety concerns that necessitate continued hospitalization.
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
- A. Substance use disorder
- B. Age greater than 45 years old
- C. Female gender
- D. Currently married
- E. Schizophrenia
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. Substance use disorder is a known risk factor for suicide as it can lead to increased impulsivity and impaired decision-making. Age greater than 45 years old is a risk factor due to factors such as isolation, health issues, and life changes. Schizophrenia is associated with a higher risk of suicide due to the symptoms of the disorder and the impact on one's mental well-being. Choices C and D are incorrect as being female or currently married are not universal risk factors for suicide. The absence of choices F and G also indicates that they are not relevant risk factors for suicide.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Rapid speech
- B. Tics
- C. Distorted perceptual field
- D. Urinary frequency
Correct Answer: A, D
Rationale: Moderate anxiety is associated with physical restlessness, rapid speech, and increased urinary frequency.