Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
A. Focus attention on meaningful tasks.
While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.
B. Decrease anxiety to a tolerable level.
Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.
C. Manipulate and control others' behaviors.
The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.
D. Limit the amount of time available to interact with others.
The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.
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Full Explanation
While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.
B. Decrease anxiety to a tolerable level.
Explanation: Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.
C. Manipulate and control others' behaviors.
The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.
D. Limit the amount of time available to interact with others.
The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.
Similar Questions
A nurse assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?
A. Dental erosion
Dental erosion can occur due to conditions like gastroesophageal reflux disease (GERD) or frequent vomiting, but it is not a characteristic feature of anorexia nervosa.
B. Hyperactive bowel sounds
Hyperactive bowel sounds are not specific to anorexia nervosa and may be seen in various gastrointestinal disorders.
C. Hypertension
Hypertension is not a common finding in individuals with anorexia nervosa. In fact, hypotension (low blood pressure) is more commonly observed due to decreased cardiac output related to malnutrition and electrolyte imbalances.
D. Bradycardia
bradycardia in a client with a new diagnosis of anorexia nervosa. Bradycardia (abnormally slow heart rate) is a common cardiovascular manifestation in individuals with anorexia nervosa. It is often a result of the body's adaptive response to conserve energy due to severe malnutrition and reduced caloric intake.
Full Explanation
A. Dental erosion can occur due to conditions like gastroesophageal reflux disease (GERD) or frequent vomiting, but it is not a characteristic feature of anorexia nervosa.
B. Hyperactive bowel sounds are not specific to anorexia nervosa and may be seen in various gastrointestinal disorders.
C. Hypertension is not a common finding in individuals with anorexia nervosa. In fact, hypotension (low blood pressure) is more commonly observed due to decreased cardiac output related to malnutrition and electrolyte imbalances.
D. bradycardia in a client with a new diagnosis of anorexia nervosa. Bradycardia (abnormally slow heart rate) is a common cardiovascular manifestation in individuals with anorexia nervosa. It is often a result of the body's adaptive response to conserve energy due to severe malnutrition and reduced caloric intake.
A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
A. Padding side rails to prevent injury.
While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.
B. Applying a cooling blanket.
While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.
C. Administering an anticonvulsant.
While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.
D. Preparing for artificial ventilation.
Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.
Full Explanation
While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.
B. Applying a cooling blanket.
While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.
C. Administering an anticonvulsant.
While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.
D. Preparing for artificial ventilation.
Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.
A nurse is teaching a client who has depression about a new prescription for fluoxetine 20 mg daily. Which of the following statements by the clients understanding of the teaching?
A. I will notice an improvement in my sex drive"
Fluoxetine and other SSRIs can actually have an impact on sexual desire and function as a side effect, often leading to decreased libido. This statement shows a misunderstanding of the medication's potential effects.
B. I should notify my provider if I develop a skin rash."
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. It's important for clients to be aware of potential side effects and know when to notify their healthcare provider. One potential serious side effect is an allergic reaction or skin rash, which could indicate an adverse response to the medication. Therefore, the client's statement about notifying the provider if a skin rash develops demonstrates their understanding of monitoring for potential adverse reactions.
C. "I should expect relief from depression within 3 to 4 days."
"Antidepressant medications like fluoxetine typically take several weeks to start showing significant improvements in symptoms. This statement reflects a misconception about the timeline for therapeutic effects.
D. "I will take my fluoxetine at bedtime so I can sleep better."
"Fluoxetine can have stimulating effects for some individuals, so it's often recommended to take it earlier in the day to avoid interference with sleep. Taking it at bedtime could potentially disrupt sleep rather than improve it.
Full Explanation
Fluoxetine and other SSRIs can actually have an impact on sexual desire and function as a side effect, often leading to decreased libido. This statement shows a misunderstanding of the medication's potential effects.
B. "I should notify my provider if I develop a skin rash."
Explanation: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression. It's important for clients to be aware of potential side effects and know when to notify their healthcare provider. One potential serious side effect is an allergic reaction or skin rash, which could indicate an adverse response to the medication. Therefore, the client's statement about notifying the provider if a skin rash develops demonstrates their understanding of monitoring for potential adverse reactions.
C. "I should expect relief from depression within 3 to 4 days."
Antidepressant medications like fluoxetine typically take several weeks to start showing significant improvements in symptoms. This statement reflects a misconception about the timeline for therapeutic effects.
D. "I will take my fluoxetine at bedtime so I can sleep better."
Fluoxetine can have stimulating effects for some individuals, so it's often recommended to take it earlier in the day to avoid interference with sleep. Taking it at bedtime could potentially disrupt sleep rather than improve it.