Nursing Elites

1. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?

• A. Allow the client to continue the ritualistic behavior initially
• B. Immediately stop the client from performing the ritual
• C. Encourage the client to perform the ritual more quickly
• D. Provide a distraction to interrupt the ritual

Correct answer: A

Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.

2. A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings should the healthcare professional expect? Select one that doesn't apply.

• A. Amenorrhea
• B. Lanugo
• C. Hypotension
• D. Hyperkalemia

Correct answer: D

Rationale: Findings in a client diagnosed with anorexia nervosa include amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa. In anorexia nervosa, electrolyte imbalances often lead to hypokalemia, which is low potassium levels, due to malnutrition and potential purging behaviors. Hyperkalemia, high potassium levels, is not a common finding in individuals with anorexia nervosa.

3. A client has been taking lithium for several years with good symptom control. The client presents in the emergency department with blurred vision, tinnitus, and severe diarrhea. Which lithium level should the nurse correlate with these symptoms?

• A. 3.7
• B. 1.7
• C. 2.6
• D. 1.3

Correct answer: B

Rationale: Symptoms such as blurred vision, tinnitus, and severe diarrhea are indicative of lithium toxicity. A lithium level of 1.7 is within the toxic range. When clients present with these symptoms, it is crucial for the nurse to correlate them with elevated lithium levels to ensure timely intervention and prevent further complications.

4. After a client with major depressive disorder undergoes electroconvulsive therapy (ECT), which of the following is a priority assessment for the nurse?

• A. Monitoring for signs of infection
• B. Monitoring for signs of respiratory distress
• C. Monitoring for signs of hypotension
• D. Monitoring for signs of bleeding

Correct answer: B

Rationale: The priority assessment for the nurse after a client undergoes electroconvulsive therapy (ECT) is monitoring for signs of respiratory distress. This is crucial due to the potential risk of complications from anesthesia, such as airway compromise or respiratory depression. Prompt identification and intervention in case of respiratory distress are essential to ensure the client's safety and well-being. Monitoring for signs of infection (Choice A) is important but not the priority immediately post-ECT. Hypotension (Choice C) and bleeding (Choice D) are also potential concerns but assessing respiratory distress takes precedence due to the immediate risk it poses to the client's well-being.

5. In the care plan of a male patient diagnosed with a dissociative disorder, the nursing diagnosis of ineffective coping is included. Which behavior demonstrated by the patient supports this nursing diagnosis?

• A. Has no memory of the physical abuse he endured.
• B. Using both alcohol and marijuana.
• C. Often reports being unaware of surroundings.
• D. Reports feelings of 'not really being here.'

Correct answer: B

Rationale: The correct answer is B because using substances like alcohol and marijuana can be a sign of ineffective coping mechanisms in patients with dissociative disorders. Substance abuse is often used as a maladaptive way to cope with stress, trauma, or other underlying issues. Choices A, C, and D may be related to dissociative symptoms but do not directly reflect ineffective coping behaviors as substance abuse does.

Similar Questions