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What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?
- A. Allow the client to continue washing her hands.
- B. Set limits on the time spent washing her hands.
- C. Encourage the client to wash her hands less frequently.
- D. Assist the client in finding alternative ways to reduce anxiety.
Correct Answer: D
Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.
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The nurse is caring for a client who is experiencing a panic attack. Which intervention should the nurse implement first?
- A. Stay with the client and remain calm.
- B. Encourage the client to express their feelings.
- C. Teach the client deep-breathing exercises.
- D. Administer prescribed anti-anxiety medication.
Correct Answer: A
Rationale: The priority intervention is to stay with the client and remain calm (A). This provides immediate support and reassurance. Encouraging the client to express their feelings (B) and teaching deep-breathing exercises (C) are important but should come after ensuring the client's immediate safety and comfort. Administering medication (D) might be necessary, but the nurse should first focus on providing a calming presence to help the client feel safe and supported during the panic attack.
A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?
- A. Remind the client that his suspicions are not true.
- B. Ask one nurse to spend time with the client daily.
- C. Encourage the client to participate in group activities.
- D. Assign the client to a room closest to the activity room.
Correct Answer: B
Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.
A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?
- A. Reassure the client that the bugs are not real.
- B. Administer the prescribed benzodiazepine.
- C. Place the client in a quiet, dark room.
- D. Encourage the client to express his feelings.
Correct Answer: B
Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.
The nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, 'Get out of here! I'll get up when I'm ready!' Which response is best for the nurse to make?
- A. Your healthcare provider has prescribed ambulation on the first postoperative day.
- B. You must ambulate to avoid complications that could cause more discomfort than ambulating.
- C. I know how you feel. You're angry about having to ambulate, but this will help you get well.
- D. I'll be back in 30 minutes to help you get out of bed and walk around the room.
Correct Answer: D
Rationale: (D) provides a 'cooling off' period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with an intellectually disabled client and is threatening the client with 'complications.' (C) is telling the client how she feels (angry), and the nurse does not really 'know' how this client feels, unless the nurse is also intellectually disabled and has also just had an appendectomy.
Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?
- A. Establish rapport in each phase of the nurse-client relationship.
- B. Determine the client's ability to communicate effectively.
- C. Reflect on previous psychiatric interviews the nurse has performed.
- D. Ensure data is collected and recorded in a systematic sequence.
Correct Answer: A
Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.