Nokea
Which clients are most likely to be members of an obsessive-compulsive disorder (OCD) support group? Select all that apply.
- A. A 30-year-old who performs handwashing five times per hour
- B. A 35-year-old who wears gloves when touching a public faucet
- C. A 40-year-old who is sexually promiscuous
- D. A 45-year-old who drinks a fifth of whiskey daily
- E. A 50-year-old who cannot throw anything away
- F. A 60-year-old who repeatedly checks the locks on locked doors
Correct Answer: A,B,E,F
Rationale: Compulsive handwashing, glove-wearing, hoarding, and lock-checking are characteristic OCD behaviors involving repetitive actions to reduce anxiety.
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The nurse is planning care for the client who has a cognitive deficit and a history of violence following head trauma. What is the primary effect of a cognitive deficit that can contribute to the client having a catastrophically violent reaction?
- A. The client’s ability to process information including instructions is limited.
- B. The client has a decreased ability to interpret and tolerate sensory stimuli.
- C. The staff has a more difficult time providing appropriate milieu boundaries.
- D. The staff’s attention is oftentimes diverted to other more manipulative clients.
Correct Answer: B
Rationale: Decreased ability to tolerate sensory stimuli (B) triggers catastrophic reactions. Processing (A) boundaries (C) and staff attention (D) are not primary contributors.
When a client with dementia says, 'I want to go home,' which response by the nurse is most appropriate?
- A. You are at home.
- B. You are staying here.
- C. You must be homesick.
- D. You need to call your family.
Correct Answer: C
Rationale: Acknowledging homesickness validates the client's feelings, redirecting the conversation therapeutically without causing distress.
The client's family asks the nurse for a list of organizations where they can go for support during this difficult time. Which resource is most appropriate in this situation?
- A. Alcoholics Anonymous
- B. Recovery Anonymous
- C. Al-Anon
- D. Synanon
Correct Answer: C
Rationale: Al-Anon is specifically designed to support family members of individuals with alcoholism, providing them with coping strategies and emotional support.
The nurse is conducting an admission history on the client being hospitalized with symptoms characteristic of schizophrenia. Which interview question demonstrates that the nurse can identify the most prevalent comorbid substance abuse issue for the client with schizophrenia?
- A. “When did you last smoke or use marijuana?”
- B. “Did you bring any street drugs to the hospital?”
- C. “How much alcohol do you drink in a 24-hour period?”
- D. “Did you give the nursing assistant all your cigarettes and lighters?”
Correct Answer: D
Rationale: Nicotine use (D) is most prevalent (70-90%) in schizophrenia. Marijuana (A) street drugs (B) and alcohol (C) are less common.
When the depressed client is scheduled for a series of electroconvulsive therapy (ECT) treatments, which reaction is most likely to be manifested in the immediate recovery period?
- A. A brief period of absence seizures
- B. Sensitivity to light and double vision
- C. Short-term memory loss and headaches
- D. Periods of unexplained fear and anxiety
Correct Answer: C
Rationale: Short-term memory loss and headaches are common post-ECT effects due to temporary brain disruption.