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. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic but responsive. The mother states, 'I think he took some of my pain pills.' During the initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: In a situation where a teenager is brought to the hospital after possibly ingesting pills, the most crucial information for the nurse to obtain from the parents is whether the teenager might have taken any other drugs (C). This knowledge is vital for guiding further treatment, such as administering antagonists, making it the top priority. While information about depression (A) and previous drug overdoses (B) is valuable for treatment planning, it is not as critical as knowing all substances taken. Asking about the teenager's desire to quit taking drugs (D) is not appropriate during the acute management of a drug overdose and does not take precedence over determining what other substances might have been ingested.

3. A nurse is caring for a client who is experiencing withdrawal symptoms from opioid addiction. What is the priority nursing intervention?

• A. Monitor for signs of respiratory depression.
• B. Administer methadone as prescribed.
• C. Provide a calm and quiet environment.
• D. Encourage fluid intake to prevent dehydration.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of respiratory depression. During opioid withdrawal, the priority is to monitor the client for respiratory depression as it can be life-threatening. Respiratory depression is a serious concern during opioid withdrawal, and prompt recognition and intervention are crucial. Administering methadone as prescribed (Choice B) may be part of the treatment plan but is not the priority in this situation. Providing a calm and quiet environment (Choice C) and encouraging fluid intake to prevent dehydration (Choice D) are important aspects of care but do not take precedence over monitoring for respiratory depression.

4. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?

• A. Allow the client to continue washing her hands.
• B. Set limits on the time spent washing her hands.
• C. Encourage the client to wash her hands less frequently.
• D. Assist the client in finding alternative ways to reduce anxiety.

Correct answer: D

Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.

5. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: Identification is the correct answer. It is a defense mechanism where an individual unconsciously models themselves after someone they admire or feel close to. In this scenario, the client is imitating the nurse's mannerisms, indicating identification. Sublimation involves channeling unacceptable impulses into socially acceptable activities. Introjection is the internalization of external attitudes or voices, while repression involves suppressing unwanted thoughts or desires.

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