Nursing Elites

1. A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?

• A. Your behavior is part of your illness, and it is important to work on changing it.
• B. It is important to understand why you feel the need to perform these behaviors.
• C. Let's figure out a way for you to control these behaviors.
• D. It sounds like you are feeling powerless to change your behavior.

Correct answer: D

Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.

2. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

• A. Agree with the client's delusions to avoid confrontation.
• B. Challenge the client's delusions directly.
• C. Encourage the client to discuss their delusions in detail.
• D. Present reality and offer reassurance without reinforcing the delusions.

Correct answer: D

Rationale: When caring for a client with schizophrenia experiencing delusions, the nurse should present reality and offer reassurance without reinforcing the client's delusions. This approach helps the client maintain a connection to reality while feeling supported. Agreeing with the delusions may perpetuate false beliefs, while directly challenging them can lead to increased distress for the client. Encouraging the client to discuss their delusions in detail may further exacerbate their symptoms or reinforce their false beliefs. Therefore, the most therapeutic intervention is to gently present reality and provide reassurance to the client.

3. Which of the following is not a symptom of a panic attack?

• A. Chest pain
• B. Shortness of breath
• C. Dizziness
• D. Hot flashes

Correct answer: A

Rationale: Symptoms of a panic attack include shortness of breath, dizziness, and hot flashes. Chest pain is not a common symptom of a panic attack but can be present in some cases. Euphoria is not typically associated with panic attacks.

4. Which of the following interventions should not be implemented for a client with anorexia nervosa?

• A. Monitor daily caloric intake and weight
• B. Establish a structured eating plan
• C. Encourage the client to exercise
• D. Provide liquid supplements as prescribed

Correct answer: C

Rationale: Interventions for a client with anorexia nervosa should focus on monitoring daily caloric intake and weight, establishing a structured eating plan, providing liquid supplements as prescribed, and offering rewards for weight gain. Encouraging exercise is not recommended as it can worsen the condition by increasing energy expenditure and potentially reinforcing unhealthy behaviors associated with anorexia nervosa.

5. A woman was abducted and raped at gunpoint by an unknown assailant. When found, she was confused and disoriented. The nurse makes the following observations about the client. She is talking rapidly in disjointed phrases, is unable to concentrate, and is indecisive when asked to make simple decisions. The client's level of anxiety can be assessed as

• A. moderate
• B. severe
• C. mild
• D. nonexistent

Correct answer: B

Rationale: The client's presentation, including rapid and disjointed speech, inability to concentrate, and indecisiveness, are indicative of severe anxiety. These symptoms suggest a high level of distress and impairment in cognitive functioning, which aligns with severe anxiety rather than mild or moderate levels. The traumatic experience of being abducted and raped at gunpoint would likely contribute to such a severe level of anxiety.

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