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 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?

• A. Place the client on seizure precautions and monitor closely.
• B. Immediately transfer the client to the ICU.
• C. Report the symptoms to the charge nurse and document in the client's chart.
• D. No action is required at this time as these are known side effects of such medications.

Correct answer: B

Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.

3. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states 'I don't need to be here,' and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?

• A. Insight and judgment.
• B. Mood and affect.
• C. Remote memory.
• D. Level of concentration.

Correct answer: A

Rationale: The correct answer is A: Insight and judgment. The client's statements indicate her lack of insight into her need for hospitalization ('I don't need to be here') and the presence of a delusion (believing that the TV talks to her). These statements reflect the client's insight into her condition and judgment. This information is crucial for assessing the client's understanding of her situation and decision-making capacity. Choice B, Mood and affect, focuses on the client's emotional state rather than her insight and judgment. Choice C, Remote memory, pertains to the ability to recall past events, which is not the primary focus of the client's statements. Choice D, Level of concentration, is not directly related to the client's statements about her need for hospitalization and the delusional belief about the TV.

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. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?

• A. The voices are telling me to kill the next person I see.
• B. The fire is burning my skin away right now.
• C. The snakes on the wall are going to eat me.
• D. The nurse at night is trying to poison me with pills.

Correct answer: D

Rationale: The correct answer is D. Believing that the nurse is trying to poison him with pills is a clear indication of delusional paranoia, a common symptom in paranoid schizophrenia. Choices A, B, and C do not directly relate to paranoid delusions and are more indicative of hallucinations or other forms of delusions not specific to paranoia.

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