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A nurse is providing teaching to a client who has obsessive-compulsive disorder and engages in excessive handwashing. Which of the following instructions should the nurse include?
- A. Encourage the client to stop washing hands
- B. Allow additional time for rituals
- C. Limit ritual behaviors immediately
- D. Ignore the compulsions
Correct Answer: B
Rationale: The correct answer is B: Allow additional time for rituals. This is because abruptly stopping the handwashing rituals can lead to increased anxiety and distress for the client. Allowing additional time for rituals can help the client feel more in control and gradually work towards reducing the behavior. Encouraging the client to stop washing hands (A) abruptly can be counterproductive. Limiting ritual behaviors immediately (C) can also increase anxiety. Ignoring the compulsions (D) may worsen the condition.
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A nurse is planning care for a 3-year-old child who has autism spectrum disorder. Which of the following findings should the nurse expect?
- A. Readily initiates conversation
- B. Enjoys imaginative play
- C. Strong relationship with sibling and peers
- D. Attachment to objects that spin
Correct Answer: D
Rationale: The correct answer is D: Attachment to objects that spin. Children with autism spectrum disorder often exhibit repetitive behaviors, such as spinning objects, as a way to self-soothe or seek sensory stimulation. This behavior can serve as a coping mechanism and provide a sense of control for the child. Other choices are incorrect because children with autism spectrum disorder may have challenges in initiating conversations (A), engaging in imaginative play (B), or forming strong relationships with siblings and peers (C). By understanding the characteristics of autism spectrum disorder, the nurse can better tailor care and interventions to support the child's unique needs.
A nurse is planning care for a client who has bipolar disorder and is experiencing a depressive episode. Which of the following interventions should the nurse include?
- A. Encourage excessive physical activity
- B. Provide frequent rest periods
- C. Discourage interaction with others
- D. Implement a rigid daily routine
Correct Answer: B
Rationale: The correct answer is B: Provide frequent rest periods. During a depressive episode in bipolar disorder, the client may experience fatigue and lack of motivation. Providing frequent rest periods allows for adequate relaxation and helps to conserve energy. This intervention supports the client in managing their symptoms and promotes self-care.
A: Encouraging excessive physical activity may exacerbate fatigue and worsen symptoms during a depressive episode.
C: Discouraging interaction with others may increase feelings of isolation and worsen depressive symptoms.
D: Implementing a rigid daily routine may add pressure and stress to the client, which can be counterproductive during a depressive episode.
A nurse in a mental facility is assessing a client for suicide risk factors using the SAD PERSONS scale. Which of the following findings indicates a risk for suicide?
- A. The client is married
- B. The client is female
- C. The client is 50 years of age
- D. The client has diabetes mellitus
Correct Answer: C
Rationale: The correct answer is C: The client is 50 years of age. The SAD PERSONS scale includes age as a risk factor for suicide. As individuals get older, they may face more challenges such as chronic health conditions, loss of loved ones, or financial difficulties, which can increase suicidal ideation. This age group is considered at higher risk for suicide compared to younger individuals. Choices A, B, and D do not directly relate to suicide risk factors according to the scale. Being married (A) can sometimes be a protective factor, being female (B) is not a specific risk factor, and having diabetes mellitus (D) is a medical condition that is not directly associated with suicide risk based on the scale.
A nurse is planning care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following interventions should the nurse include?
- A. Encourage the client to listen to loud music
- B. Ask the client directly about the content of the hallucinations
- C. Instruct the client to ignore the voices
- D. Avoid discussing the hallucinations with the client
Correct Answer: B
Rationale: The correct answer is B: Ask the client directly about the content of the hallucinations. This intervention is important as it helps the nurse understand the nature and content of the hallucinations, allowing for better assessment and tailored intervention. By directly asking the client, the nurse can gather valuable information to provide appropriate care and support. Encouraging the client to listen to loud music (A) may exacerbate the hallucinations. Instructing the client to ignore the voices (C) may not be effective and could lead to increased distress. Avoiding discussing the hallucinations with the client (D) hinders the therapeutic communication and understanding of the client's experience.
A nurse in a psychiatric facility is planning care for a client who has depression and is at risk for suicide. Which of the following interventions should the nurse implement?
- A. Assign the same staff to the client each shift
- B. Keep the client's room well-lit at all times
- C. Allow the client privacy at all times
- D. Provide access to sharp objects
Correct Answer: A
Rationale: The correct answer is A: Assign the same staff to the client each shift. Consistency in staff helps build trust and rapport, crucial for clients with depression and suicide risk. This continuity allows staff to better monitor the client's behavior, mood changes, and suicide risk factors. The familiarity also helps in identifying early warning signs and implementing appropriate interventions promptly.
Choice B is incorrect because while keeping the room well-lit may help prevent self-harm, it does not address the underlying need for consistent support and monitoring.
Choice C is incorrect as constant privacy may hinder the nurse's ability to assess the client's safety and intervene effectively.
Choice D is incorrect as providing access to sharp objects increases the client's risk of self-harm.