Nursing Elites

1. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

• A. Anxiety
• B. Hostility
• C. Aggression
• D. Withdrawal

Correct answer: A

Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.

2. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

• A. "I know you are capable of giving yourself the insulin."
• B. "Giving yourself the injection seems to make you nervous."
• C. "When I watched you give yourself the injection, you did it correctly."
• D. "Tell me what you want me to do to help you give yourself the injection at home."

Correct answer: C

Rationale: The most appropriate response by the nurse in this scenario is option C. By acknowledging and affirming the client's demonstrated ability to self-administer the injection correctly, the nurse is providing positive reinforcement. This positive reinforcement helps to build the client's confidence and encourages them to take total responsibility for their daily injections. Option A, while positive, does not specifically reinforce the client's behavior related to giving the injection. Option B focuses on the client's feelings of nervousness, which may not be helpful in promoting independence. Option D, by offering help without assessing the client's actual needs, reinforces dependence on the nurse rather than encouraging self-reliance.

3. A newly diagnosed client with human immunodeficiency virus (HIV) comments to the nurse, 'There are so many rotten people around. Why couldn't one of them get HIV instead of me?' Which statement is the nurse's best response?

• A. 'I can understand why you are afraid of dying.'
• B. 'It seems unfair that you contracted this disorder.'
• C. 'Do you really wish this disorder on someone else?'
• D. 'Have you thought of speaking with your religious adviser?'

Correct answer: B

Rationale: The client is expressing feelings of unfairness and questioning why they have HIV. The nurse's best response is to acknowledge the client's emotions. Choice B, 'It seems unfair that you contracted this disorder,' reflects empathy and validates the client's feelings, which can help them move towards acceptance. Choice A, 'I can understand why you are afraid of dying,' introduces the topic of death, which may not be the primary concern at this stage. Choice C, 'Do you really wish this disorder on someone else?' is judgmental and could induce guilt in the client. Choice D, 'Have you thought of speaking with your religious adviser?' deflects the conversation and does not address the client's current emotional needs.

4. The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?

• A. Place the client in a high Fowler position.
• B. Assist the client in assuming a left side-lying position.
• C. Measure the tube from the tip of the nose to the xiphoid process.
• D. Assist the client in flexing the neck forward to facilitate tube insertion.

Correct answer: A

Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.

5. According to psychodynamic theory, what purpose do delusions serve?

• A. Delusions are a defense against anxiety caused by real or imagined threats.
• B. Magical thinking is a delusion that ensures desirable outcomes.
• C. Delusions are a method of dealing with and interpreting external stimuli.
• D. Subconsciously, delusions are a way to safely express anger and hostility.

Correct answer: A

Rationale: According to psychodynamic theory, delusions serve as a defense mechanism against anxiety triggered by real or perceived threats. Delusions are the individual's unconscious way of protecting themselves from overwhelming feelings of anxiety. Magical thinking, on the other hand, involves believing that one's thoughts can influence external events. This is not the same as delusions. Delusions are not a way of interpreting external stimuli but rather a defense mechanism. Expressing anger and hostility is typically associated with defense mechanisms like displacement or projection, not delusions.

Similar Questions