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A patient with obsessive-compulsive disorder (OCD) is performing a ritualistic handwashing routine. What is the nurse's best initial response?
- A. Interrupt the ritual to help the patient gain control.
- B. Allow the ritual but set limits on the duration.
- C. Ignore the behavior to avoid reinforcing it.
- D. Encourage the patient to stop the ritual and discuss their feelings.
Correct Answer: B
Rationale: In managing a patient with OCD engaging in ritualistic behaviors like handwashing, the nurse's best initial response is to allow the ritual but set limits on the duration. This approach helps in managing the behavior while gradually working towards reducing its frequency. Interrupting the ritual abruptly may cause distress to the patient, ignoring the behavior may reinforce it, and encouraging the patient to stop the ritual without setting limits may not be as effective in the initial stage of intervention.
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A patient with major depressive disorder is being treated with electroconvulsive therapy (ECT). The nurse should monitor the patient for which common side effect?
- A. Memory loss
- B. Hypertension
- C. Weight gain
- D. Hyperglycemia
Correct Answer: A
Rationale: Memory loss, especially short-term memory loss, is a common side effect associated with electroconvulsive therapy (ECT). During ECT treatment, the electrical currents passed through the brain can disrupt short-term memory formation. This side effect is usually temporary, but patients should be closely monitored for any changes in memory function during and after the treatment. Choices B, C, and D are incorrect because they are not commonly associated with ECT. Hypertension, weight gain, and hyperglycemia are not typically observed as side effects of ECT.
When a patient with major depressive disorder is started on fluoxetine, what is the most important side effect for the nurse to monitor?
- A. Weight gain
- B. Suicidal ideation
- C. Hypertension
- D. Hyperglycemia
Correct Answer: B
Rationale: When initiating fluoxetine therapy in a patient with major depressive disorder, monitoring for suicidal ideation is crucial due to the increased risk of suicidal thoughts or behaviors that can occur, especially in the initial phase of treatment. This close monitoring is essential to ensure patient safety and intervene promptly if such symptoms arise. Weight gain, hypertension, and hyperglycemia are potential side effects of some medications used to treat depression, but suicidal ideation is the most critical and immediate side effect to monitor for when starting fluoxetine.
What information should the nurse include in patient education for a patient prescribed fluoxetine for obsessive-compulsive disorder (OCD)?
- A. Take the medication in the morning to avoid insomnia.
- B. The medication may take several weeks to achieve the full effect.
- C. It is safe to consume alcohol while taking this medication.
- D. Report any side effects to the healthcare provider immediately.
Correct Answer: B
Rationale: Patients prescribed fluoxetine should be educated that the medication may take several weeks to achieve its full therapeutic effect. This information helps manage patient expectations and ensures they do not discontinue the medication prematurely due to lack of immediate results. Taking the medication in the morning to avoid insomnia is not a specific requirement for fluoxetine. Consuming alcohol while taking fluoxetine is not safe and can lead to adverse effects. It is crucial to report any side effects to the healthcare provider promptly for timely management and adjustment of the treatment plan.
A patient with agoraphobia is unable to leave home. Which intervention should the nurse prioritize?
- A. Teach the patient relaxation techniques.
- B. Gradual exposure to feared situations.
- C. Encourage the patient to attend social gatherings.
- D. Provide education about the disorder.
Correct Answer: B
Rationale: For a patient with agoraphobia, the priority intervention should be gradual exposure to feared situations. This approach helps the patient confront and gradually overcome their fear of leaving home, a common challenge in agoraphobia. By exposing the patient to feared situations in a step-by-step manner, they can learn to manage their anxiety and increase their confidence in leaving home. Teaching relaxation techniques (Choice A) can be beneficial but may not address the core issue of avoidance behavior. Encouraging the patient to attend social gatherings (Choice C) can be overwhelming and counterproductive at the initial stage of treatment. Providing education about the disorder (Choice D) is important but should come after addressing the immediate need for exposure therapy.
A patient with schizophrenia is experiencing hallucinations. Which intervention is most appropriate?
- A. Encourage the patient to ignore the voices.
- B. Engage the patient in a reality-based activity.
- C. Provide a quiet environment to reduce stimulation.
- D. Ask the patient to describe the hallucinations in detail.
Correct Answer: B
Rationale: Engaging the patient in a reality-based activity is the most appropriate intervention for a patient with schizophrenia experiencing hallucinations. This intervention can help distract the patient from the hallucinations and reorient them to the present, promoting a connection with reality and potentially reducing distress associated with the hallucinations. Choice A, encouraging the patient to ignore the voices, may not be effective as it can be challenging for the patient to dismiss the hallucinations. Choice C, providing a quiet environment, is helpful but may not directly address the hallucinations. Choice D, asking the patient to describe the hallucinations in detail, may increase the patient's focus on the hallucinations, potentially worsening distress.