Nursing Elites

1. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

2. Which of the following actions will most likely lead to a break in the sterile technique for respiratory isolation?

• A. Opening the patient’s window to the outside environment
• B. Turning on the patient’s room ventilator
• C. Opening the door of the patient’s room leading into the hospital corridor
• D. Failing to wear gloves when administering a bed bath

Correct answer: D

Rationale: Failure to wear gloves during a bed bath can potentially introduce pathogens, compromising the sterile technique necessary for respiratory isolation. Proper hand hygiene and personal protective equipment are crucial to prevent the transmission of infectious agents in such settings.

3. A healthcare provider is caring for a client following a thoracentesis. Which of the following manifestations should the healthcare provider NOT recognize as risks for complications?

• A. Dyspnea
• B. Localized bloody drainage on the dressing
• C. Fever
• D. Hypotension

Correct answer: B

Rationale: After a thoracentesis, some expected complications include dyspnea, fever, and hypotension. Localized bloody drainage on the dressing is a common and expected finding post-thoracentesis due to the procedure's nature of puncturing the chest wall. Therefore, the healthcare provider should not consider this finding as a risk for complications.

4. A client has global aphasia affecting both receptive and expressive language abilities. Which intervention should NOT be included in the client's care plan?

• A. Speak to the client at a slower rate.
• B. Assist the client in using flash cards with pictures.
• C. Speak to the client in a loud voice.
• D. Give instructions one step at a time.

Correct answer: C

Rationale: Individuals with global aphasia have difficulty understanding and expressing language. Speaking loudly may not improve comprehension and can be perceived as aggressive. Therefore, it is important not to speak loudly to a client with global aphasia. Speaking at a slower rate, using visual aids like flash cards, and breaking down instructions into simple steps can facilitate communication and understanding for the client.

5. What is the best position for examining the rectum?

• A. Prone
• B. Sim's
• C. Knee-chest
• D. Lithotomy

Correct answer: C

Rationale: The knee-chest position is the most optimal position for examining the rectum. In this position, the patient kneels on the examination table with their chest resting on it, creating a straight line from the head to the lower back. This position allows for easier access and visualization of the rectal area, making it the preferred choice for rectal examinations. Prone position (choice A) is lying face down and is not ideal for rectal exams as it does not provide good access. Sim's position (choice B) is lying on the left side with the right knee and thigh flexed, also not ideal for rectal exams. Lithotomy position (choice D) is lying on the back with legs flexed and feet in stirrups, primarily used for gynecological exams and surgery, not for rectal examinations.

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