A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Ask the client why she checks the locks.

Determine the type and size of the locks.

Discuss checking the time frequently.

Plan a list of activities to be carried out daily.

Answer and Explanation

The Correct Answer is D

A. "Ask the client why she checks the locks."
Asking "why" questions may put the client on the defensive and does not effectively address the compulsive behavior. Clients with obsessive-compulsive disorder (OCD) often do not have a logical explanation for their compulsions.

B. "Determine the type and size of the locks."
This action does not address the client’s compulsive behavior and is not relevant to the nursing intervention. The focus should be on reducing the compulsive behavior rather than assessing the locks themselves.

C. "Discuss checking the time frequently."
This response does not directly address the client’s compulsive checking behavior. Instead, structured interventions that promote time management and coping strategies should be implemented.

D. "Plan a list of activities to be carried out daily."
Providing a structured daily schedule can help redirect the client’s focus away from compulsive behaviors and toward productive activities. A schedule can reduce anxiety and limit the time available for compulsions, promoting better functioning.

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Correct Answer is D

Explanation

Choice A rationale:
An adult with schizophrenia who often refuses to take prescribed antipsychotic medications may require a different approach, such as medication education or supportive therapy.

Choice B rationale:
A hyperactive 4-year-old who has recently been tested for autism may benefit from play therapy or other age-appropriate interventions rather than role-playing.

Choice C rationale:
An older adult resident of a long-term care facility who sometimes takes other residents' belongings may require interventions focused on behavior management and addressing the underlying causes of this behavior.

Choice D rationale:
Role-playing can be an effective therapeutic intervention for individuals who need to practice social skills, communication, and problem-solving in a safe and controlled environment. In this case, the adolescent who is depressed over not being accepted by peers may benefit from role-playing to develop and practice social skills, assertiveness, and coping strategies for peer interactions.

A. Bradycardia and bradypnea. B. Stimulation and dilated pupils. C. Hallucinations and delusions. D. Lethargy and depression.

Correct Answer is B

Explanation

Choice A rationale:
Cocaine is a stimulant and typically leads to increased heart rate (tachycardia) and respiratory rate (tachypnea). Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) would be atypical findings with cocaine use.

Choice B rationale:
Cocaine is a stimulant drug that typically produces effects such as increased heart rate, increased blood pressure, stimulation, euphoria, and dilated pupils. These physiological and psychological effects are common when someone has used cocaine.

Choice C rationale:
While cocaine use can cause hallucinations and paranoia during intoxication or withdrawal, these symptoms are not typically the primary manifestations. The most common initial effects are stimulation and increased alertness.
Hallucinations and delusions may occur with substance use, but they are not the most expected or specific findings for cocaine use.

Choice D rationale:
Cocaine use is associated with increased energy, euphoria, and heightened arousal. Lethargy and depression are more likely during the comedown phase or withdrawal from cocaine, rather than immediately after use.

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A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Correct Answer is D

Explanation

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Correct Answer is B

Explanation

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?