Nursing Elites

1. A client with obsessive-compulsive disorder (OCD) spends hours checking and rechecking the locks on the doors. What is the best nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to discuss the thoughts and feelings behind the behavior.
• C. Prevent the client from checking the locks to break the cycle.
• D. Schedule specific times for the client to check the locks.

Correct answer: B

Rationale: The best nursing intervention for a client with OCD who spends excessive time checking locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can gain insight and work towards behavior modification. Choice A is incorrect because enabling the behavior does not address the underlying issues. Choice C is incorrect as it may lead to increased anxiety and distress. Choice D is incorrect as it does not address the root cause of the behavior.

2. A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client's arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

• A. Vomiting, seizures, and loss of consciousness.
• B. Depression, fatigue, and dizziness.
• C. Hypotension, shallow respirations, and dilated pupils.
• D. Agitation, sweating, and abdominal cramps.

Correct answer: D

Rationale: Agitation, sweating, and abdominal cramps are early signs of narcotic withdrawal. Vomiting, seizures, and loss of consciousness (Option A) are more indicative of severe withdrawal or overdose symptoms. Depression, fatigue, and dizziness (Option B) are not typically early signs of narcotic withdrawal. Hypotension, shallow respirations, and dilated pupils (Option C) are more associated with opioid overdose rather than withdrawal. Monitoring for agitation, sweating, and abdominal cramps is crucial for managing narcotic withdrawal symptoms effectively.

3. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The LPN/LVN notes that the client has not bathed or dressed in clean clothes for several days. What is the most appropriate intervention for the nurse to implement?

• A. Encourage the client to take a shower.
• B. Assist the client with activities of daily living.
• C. Provide the client with clean clothes to change into.
• D. Explain the importance of personal hygiene to the client.

Correct answer: B

Rationale: The correct answer is to assist the client with activities of daily living. This intervention is the most appropriate as it directly addresses the client's immediate needs by providing assistance with personal hygiene and dressing. It promotes self-care and ensures the client's well-being. Encouraging the client to take a shower (Choice A) may not be effective if the client is unable to do so independently due to their condition. Providing clean clothes (Choice C) is important but does not address the client's need for assistance with personal care. Explaining the importance of personal hygiene (Choice D) may not be as effective as providing direct assistance in this situation.

4. During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?

• A. Allow the client to engage in any activities they choose.
• B. Provide a quiet and structured environment.
• C. Encourage the client to participate in group activities.
• D. Allow the client to take short naps during the day.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder often experience excessive energy and impulsivity. Providing a quiet and structured environment is crucial to help manage these symptoms. This intervention promotes stability, reduces overstimulation, and supports the client in regaining control over their behaviors. Choices A and C may exacerbate impulsivity and overstimulation, while choice D does not address the need for environmental structure and may not be effective in managing manic symptoms.

5. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Direct the client to occupational therapy to distract him from somatic complaints.
• D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia can be a side effect of antipsychotic medications like risperidone, leading to involuntary muscle contractions and abnormal postures. Benztropine is an anticholinergic medication commonly used to treat dystonia. Choices A, B, and C are incorrect because thioridazine is not the appropriate medication in this case, a hot pack would not address the underlying issue of dystonia, and occupational therapy is not the primary intervention for addressing acute dystonic reactions.

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