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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.
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A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
A nurse is caring for a client who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Expressive affect
- B. Associative looseness
- C. Echolalia
- D. Ambivalence
Correct Answer: C
Rationale: Echolalia, or repeating words/phrases, is a common communication pattern in autism spectrum disorder.
Which medication is commonly prescribed to treat obsessive-compulsive disorder (OCD)?
- A. Paroxetine
- B. Lithium
- C. Donepezil
- D. Valproate
- E. Carbamazepine
Correct Answer: A
Rationale: The correct answer is A: Paroxetine. Paroxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for OCD due to its effectiveness in increasing serotonin levels in the brain, which helps reduce obsessive thoughts and compulsive behaviors. Lithium, Donepezil, Valproate, and Carbamazepine are not typically used to treat OCD as they are more commonly indicated for conditions such as mood disorders, Alzheimer's disease, epilepsy, and bipolar disorder, respectively. Therefore, Paroxetine is the most appropriate choice for treating OCD based on its mechanism of action and proven efficacy.
How should a nurse address compulsive behaviors in a newly admitted client with OCD?
- A. Isolate the client
- B. Confront the client about the behavior
- C. Encourage participation in group activities
- D. Set strict limits on behaviors
- E. Allow additional time for rituals
Correct Answer: D
Rationale: Correct Answer: D. Set strict limits on behaviors
Rationale:
1. Setting strict limits helps establish boundaries and structure for the client.
2. It assists in reducing compulsive behaviors by providing clear guidelines.
3. It promotes a sense of control and safety for the client.
4. Allows for gradual exposure and response prevention therapy.
Summary:
A: Isolating the client can exacerbate feelings of loneliness and increase anxiety.
B: Confrontation may trigger defensiveness and hinder therapeutic rapport.
C: While group activities can be beneficial, they may not directly address the compulsive behaviors.
E: Allowing additional time for rituals reinforces maladaptive behaviors.