Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is developing a plan of care for a client who has obsessive-compulsive disorder.
Which of the following interventions should the nurse include?
A. Allow the client autonomy in scheduling daily activities.
Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.
B. Administer an antipsychotic medication to the client.
Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.
C. Provide ample time for rituals in the early treatment stages.
Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.
D. Initiate implosion therapy for the client.
Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.
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Full Explanation
Choice A rationale:
Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.
Choice B rationale:
Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.
Choice C rationale:
Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.
Choice D rationale:
Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.
Similar Questions
A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?
A. Check cervical dilation every 2 hr.
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
B. Initiate an IV with an 18-gauge catheter.
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
C. Monitor FHR hourly.
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
D. Obtain vital signs every 4 hr.
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
Full Explanation
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
A nurse is assessing a client who is experiencing postpartum hemorrhage. Which of the following findings should the nurse identify as an indication of excessive blood loss?
A. Tachycardia
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
B. Flushed skin
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
C. Polyuria
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
D. Firm fundus
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
Full Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
Choice B rationale:
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
Choice C rationale:
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
Choice D rationale:
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
A nurse is preparing an educational program about sexual assault for a group of college students. Which of the following information should the nurse include?
A. Survivors of sexual assault exhibit similar psychological symptoms to one another.
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
B. Survivors of sexual assault do not benefit from psychotherapy.
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
C. Survivors of sexual assault often know their offender.
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers. Education should provide accurate and evidence-based information to address misconceptions.
D. Survivors of sexual assault are generally married living in metropolitan areas.
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.
Full Explanation
Choice A rationale:
Survivors of sexual assault can exhibit a wide range of psychological symptoms, and their experiences may vary significantly. There is no universal pattern of symptoms that applies to all survivors.
Choice B rationale:
Psychotherapy, such as trauma-focused cognitive-behavioral therapy, has been shown to be effective in helping survivors of sexual assault cope with and heal from their experiences.
Choice C rationale:
Rationale:
It is important to emphasize that sexual assault survivors often know the perpetrator, as this information dispels the myth that most assaults are committed by strangers.
Education should provide accurate and evidence-based information to address misconceptions.
Choice D rationale:
Survivors of sexual assault come from diverse backgrounds and living situations, and their marital status or residence in metropolitan areas is not universally applicable.