A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?

Provide information on stress reduction methods.

Assist the client to identify triggers to obsessive behaviors.

Speak to the client in a calm and soothing manner.

Assist the client in identifying his anxiety level.

Answer and Explanation

The Correct Answer is B

Choice A reason: While providing information on stress reduction is helpful, it is not the immediate priority.

Choice B reason: Assisting the client to identify triggers is a priority as it directly addresses the cause of the OCD behaviors.

Choice C reason: Speaking to the client in a calm manner is supportive but does not address the underlying OCD behaviors.

Choice D reason: Identifying anxiety levels can be part of the intervention, but it is not as specific as identifying triggers for the OCD behaviors.

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Correct Answer is ["A","E"]

Explanation

Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.

Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.

Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.

Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.

Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.

A. Unconsciousness B. Tachycardia C. Cold clammy skin D. Diminished urine output

Correct Answer is B

Explanation

Choice A reason: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.

Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.

Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.

Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.

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A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?

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Naxlex Comprehensive Predictor Exams

A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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