Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a newly admitted client who has obsessive-compulsive disorder and frequently performs ritualistic behaviors. The nurse should expect which of the following client responses if ritualistic behavior is restricted?
A. Replaces it with a different ritualistic behavior
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
B. Reports auditory hallucinations
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
C. Expresses relief from not having to perform the ritual
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
D. Experiences panic-level anxiety
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
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Full Explanation
Choice A rationale:
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
Choice B rationale:
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
Choice C rationale:
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
Choice D rationale:
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
Similar Questions
A nurse is caring for a client who is experiencing a crisis. Which of the following actions should the nurse take first?
A. Refer the client to crisis intervention services.
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
B. Determine the client's previous methods of coping with crisis.
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
C. Discuss with the client the cause of the crisis.
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
D. Assist the client to develop strategies to overcome the crisis.
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
Full Explanation
Choice A rationale:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?
A. Call the rapid response team.
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
B. Prepare the client for intubation.
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
C. Obtain an ABG level.
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
D. Administer diphenhydramine.
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
Full Explanation
Choice A rationale:
The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.
Choice B rationale:
Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.
Choice C rationale:
Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.
Choice D rationale:
Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.
A nurse is providing teaching to the parents of a child who has cerebral palsy and a new prescription for baclofen. The nurse should instruct the parents to monitor the child for which of the following adverse effects of the medication?
A. Rhinorrhea
Rhinorrhea is not a common adverse effect of baclofen.
B. Hirsutism
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
C. Tachycardia
Tachycardia is not a common adverse effect of baclofen.
D. Constipation
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.
Full Explanation
Choice A rationale:
Rhinorrhea is not a common adverse effect of baclofen.
Choice B rationale:
Hirsutism (excessive hair growth) is not a common adverse effect of baclofen.
Choice C rationale:
Tachycardia is not a common adverse effect of baclofen.
Choice D rationale:
Constipation is a common adverse effect of baclofen. Baclofen is a muscle relaxant that can affect the gastrointestinal system, leading to reduced bowel motility and constipation.