Nokea
The nurse is with a client with obsessive-compulsive disorder who counts backwards several times each day. Which of the following statements by the client would indicate an improvement in the client's condition? Select all that apply.
- A. I take a short, brisk walk to decompress when I begin to feel anxious.
- B. My neighbor goes grocery shopping for me because I get anxious and begin counting.
- C. Having a stressful job worsens my anxiety, but I use deep-breathing exercises to manage it.
- D. Counting helps me cope with my anxiety. It does not hurt anyone, and it is better than drinking alcohol.
- E. I used to start counting as soon as I boarded the bus, but now I can ride the bus for 30 minutes without counting.
Correct Answer: A,C,E
Rationale: Statements A, C, and E indicate improvement as the client uses adaptive coping strategies (walking, deep breathing) and reports reduced compulsive behavior (delayed counting). Statement B shows reliance on others, and D justifies the compulsion, both indicating no improvement.
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The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
- A. Death is personified as the bogeyman or devil
- B. Death is perceived as being irreversible
- C. The child feels guilty for the grandmother's death
- D. The child is worried that he, too, might die
Correct Answer: A
Rationale: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.
The client is admitted for a bronchoscopy this morning. Which question is essential for the nurse to ask the client?
- A. When did you last eat?'
- B. Did you take the laxative as ordered?'
- C. What has the doctor told you about your procedure?'
- D. Have you had conscious sedation before?'
Correct Answer: A
Rationale: Bronchoscopy requires NPO status to prevent aspiration; confirming last intake is essential. Laxatives, procedure knowledge, or sedation history are secondary.
A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?
- A. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
- B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently
- C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
- D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor
Correct Answer: C
Rationale: This technique (C) ensures the nurse maintains balance with feet apart and uses their leg to guide the client safely to the floor, minimizing injury risk to both. Option A risks the nurse losing balance, B places the nurse in an unsafe position, and D involves improper body mechanics.
The nurse is preparing to give an adult a subcutaneous injection of heparin. What should the nurse check prior to giving the medication?
- A. International normalized ratio (INR)
- B. Bleeding time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: D
Rationale: Partial thromboplastin time (PTT) monitors heparin's anticoagulant effect, ensuring safe administration by assessing bleeding risk.