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When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?
- A. Allow the client enough time to perform rituals
- B. Give the client autonomy in scheduling activities
- C. Discourage the client from exploring irrational fears
- D. Provide negative reinforcement for ritualistic behaviors
Correct Answer: A
Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.
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During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?
- A. Low back pain.
- B. Dyspnea.
- C. Hypotension.
- D. Thready pulse.
Correct Answer: B
Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.
A client has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan?
- A. Place the client's left arm on a pillow while he is sitting.
- B. Provide total care in assisting with the client's ADLs.
- C. Encourage mobility and avoid bed rest.
- D. Facilitate feeding by placing food on the left side of the client's mouth when ready to eat.
Correct Answer: A
Rationale: Placing the client's left arm on a pillow while sitting helps prevent shoulder displacement and assists in maintaining proper positioning and alignment. This intervention is crucial to prevent complications associated with immobility. Providing total care in ADLs may hinder the client's independence and recovery. Encouraging mobility is essential in preventing complications of immobility. Facilitating feeding by placing food on the unaffected side of the mouth helps reduce the risk of aspiration in clients with dysphagia.
A healthcare professional is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the healthcare professional report to the provider?
- A. WBC count 8,000/mm³
- B. Platelets 150,000/mm³
- C. Aspartate aminotransferase 10 units/L
- D. Erythrocyte sedimentation rate 75 mm/hr
Correct Answer: D
Rationale: In clients with rheumatoid arthritis, an elevated erythrocyte sedimentation rate (ESR) is a common finding and indicates inflammation in the body. A high ESR value suggests active disease activity and potential joint damage. Therefore, the healthcare professional should report an ESR of 75 mm/hr to the provider for further evaluation and management of the client's rheumatoid arthritis.
A client with vision loss is under the care of a nurse. Which of the following actions should the nurse AVOID?
- A. Keep objects in the client's room in the same place
- B. Ensure there is high-wattage lighting in the client's room
- C. Approach the client from the side
- D. Allow extra time for the client to perform tasks
Correct Answer: C
Rationale: Approaching a client with vision loss from the side can startle them and may lead to accidents or discomfort. It is important to approach them from the front so they are aware of your presence. Keeping objects in the same place aids in familiarity and reduces the risk of falls. High-wattage lighting enhances visibility for the client. Allowing extra time for tasks accommodates the client's potential slower pace and ensures they can perform tasks safely.
A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?
- A. Confront the client about this behavior.
- B. Express sympathy for the client's situation.
- C. Speak assertively to the client.
- D. Stand within 30 cm (1 ft) of the client when speaking with them.
Correct Answer: A
Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.