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 female client with major depression is prescribed fluoxetine (Prozac). She reports experiencing increased energy but still feels sad and hopeless. What is the nurse's best response?

• A. ''These feelings are normal and will pass with time.''
• B. ''Increased energy can sometimes lead to increased risk for self-harm.''
• C. ''The medication needs more time to be effective.''
• D. ''Let's talk about the things that make you feel this way.''

Correct answer: B

Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.

3. A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important?

• A. How do you think you will be punished?
• B. Please tell staff when you think you need to punish yourself.
• C. What exactly do you think you have done to be punished?
• D. Let's talk about your strengths

Correct answer: B

Rationale: The most important response by the LPN/LVN is to encourage the client to communicate with staff when they feel the need to punish themselves. This approach can help assess the risk of self-harm and enable appropriate intervention. Choice A focuses more on the method of punishment rather than encouraging help-seeking behavior. Choice C seeks specific details about the perceived wrongdoing rather than addressing the immediate concern of self-punishment. Choice D, discussing strengths, does not directly address the client's current distress and potential self-harm risk.

4. A client with obsessive-compulsive disorder (OCD) repeatedly washes her hands throughout the day. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to talk about the underlying fears.
• C. Restrict the client's access to soap and water.
• D. Schedule a time for the client to perform the ritual.

Correct answer: B

Rationale: Encouraging the client to talk about the underlying fears is the most therapeutic nursing intervention for a client with OCD who repeatedly washes her hands. By discussing the fears, the client can gain insight into the behavior and work towards reducing the compulsion. Choice A is incorrect as allowing the client to continue the behavior can perpetuate the OCD symptoms. Choice C is incorrect as restricting access to soap and water can lead to increased anxiety and distress. Choice D is incorrect as scheduling a time for the client to perform the ritual does not address the underlying fears driving the behavior.

5. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

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