Nursing Elites

1. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the best nursing intervention?

• A. Encourage the client to discuss their fears.
• B. Limit the client's time for ritualistic behavior.
• C. Assist the client to complete the ritual faster.
• D. Prevent the client from engaging in the behavior.

Correct answer: A

Rationale: The best nursing intervention when dealing with a client with OCD who repeatedly checks locks is to encourage the client to discuss their fears. This approach can help the client identify underlying anxiety triggers and work towards developing alternative coping mechanisms. Choice B, limiting the client's time for ritualistic behavior, may increase anxiety and worsen symptoms by creating a sense of urgency. Choice C, assisting the client to complete the ritual faster, does not address the underlying issues and may reinforce the behavior. Choice D, preventing the client from engaging in the behavior, can lead to increased anxiety and distress for the client.

2. A client with depression is prescribed an SSRI. The client asks, 'Why do I need to take this medication every day?' What is the best response by the nurse?

• A. This medication will help balance the chemicals in your brain.
• B. This medication needs to be taken regularly to be effective.
• C. This medication will start working immediately to improve your mood.
• D. You should take this medication only when you feel sad or depressed.

Correct answer: D

Rationale: Explaining that the medication may take several weeks to take full effect helps manage the client's expectations and encourages adherence to the prescribed treatment.

3. A male client with schizophrenia tells the nurse that the voices he hears are saying, 'You must kill yourself.' To assist the client in coping with these thoughts, which response is best for the nurse to provide?

• A. Tell yourself that the voices are unreasonable.'
• B. Exercise when you hear the voices.'
• C. Talk to someone when you hear the voices.'
• D. The voices aren't real, so ignore them.'

Correct answer: A

Rationale: The nurse should teach the client to use self-talk to disprove the voices. Although exercising may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others. Auditory hallucinations are often relentless, so it is difficult to ignore them.

4. A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?

• A. Stay with the client and ensure her safety.
• B. Inform the client that she is safe in the hospital.
• C. Document the client's statements in her medical record.
• D. Encourage the client to join a group therapy session.

Correct answer: A

Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.

5. 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.

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