a nurse is creating a plan of care for a newly admitted client who has obsessivecompulsive disorder which of the following interventions should the nu
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2023

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?

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. A client reports that the medication the nurse is administering appears different than what they take at home. Which of the following responses should the nurse take?

Correct answer: A

Rationale: When a client reports that the medication appears different than what they take at home, it is crucial for the nurse to ensure the safety and accuracy of the medication being administered. The most appropriate action for the nurse to take in this situation is to call the pharmacist to verify the medication, dosage, and any potential changes. This proactive step helps prevent medication errors and ensures the client's safety and well-being.

3. The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

Correct answer: D

Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.

4. What is the primary purpose of handwashing?

Correct answer: B

Rationale: The primary purpose of handwashing is to prevent the transfer of microorganisms. Proper hand hygiene helps reduce the risk of spreading harmful bacteria and viruses, thus promoting overall health and preventing infections. Choice A is incorrect as handwashing primarily focuses on cleanliness rather than promoting circulation. Choice C is incorrect as it implies that the main concern is avoiding client discomfort rather than preventing infection. Choice D is incorrect as while handwashing can be comforting in some situations, its primary purpose is not to provide comfort but to maintain hygiene.

5. In Maslow’s hierarchy of physiological needs, the human need of greatest priority is:

Correct answer: D

Rationale: In Maslow’s hierarchy of physiological needs, the most basic and immediate need is physiological survival, which includes the need for oxygen. Without oxygen, the body cannot survive for more than a few minutes, making it the highest priority physiological need according to Maslow's hierarchy.

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