The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?

Encourage the client to be calm and relax for a little while.

Teach the client thought stopping techniques and ways to refocus behaviors.

Assist the client to identify stimuli that precipitates the activity.

Allow time for the behavior and then redirect the client to other

Answer and Explanation

The Correct Answer is D

A. Simply encouraging the client to be calm and relax may not be effective for someone with obsessive-compulsive disorder.

Teaching techniques is more appropriate for structured therapy sessions rather than addressing compulsive behavior in the moment.

C. While identifying stimuli can be useful, it is not an immediate intervention.

This approach respects the client’s need to complete the compulsion to reduce anxiety while gradually redirecting attention, minimizing distress.

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Correct Answer is B

Explanation

A. An abdominal binder can be worn daily to reduce the protrusion: This is not an appropriate intervention for an umbilical hernia in an infant. Abdominal binders are typically used for support after abdominal surgeries or to manage hernias in adults.

B. This hernia is a normal variation that resolves without treatment: Umbilical hernias are common in infants and typically resolve on their own without intervention by around 1 to 2 years of age. Reassuring the mother about the benign nature of the hernia is appropriate.

C. The quarter should be secured with an elastic bandage wrap: Taping a quarter over the umbilicus is not a recommended treatment for an umbilical hernia and could pose a choking hazard to the infant.

D. Restrictive clothing will be adequate to help the hernia go away: Restrictive clothing is not an effective treatment for umbilical hernias in infants and could potentially cause discomfort or complications.

A. Encourage the nurse to flush the tube with more water. B. Instruct the nurse to administer each medication separately. C. Add the liquid volumes when documenting fluid intake. D. Confirm that the nurse determined the amount of gastric residual. E. Advise the nurse to use the plunger when giving medications

Correct Answer is ["A","B","C","D"]

Explanation

A. The tube should be flushed with at least 15–30 mL of water before, between, and after medication administration to prevent clogging and ensure full delivery of the medications.

B. Instructing the nurse to administer each medication separately is correct. This is important to prevent drug interactions within the tube and to ensure accurate dosing. Administering
medications separately allows for proper absorption and can prevent complications such as clogging of the tube.

C. Adding the liquid volumes when documenting fluid intake is correct. It is essential to account for all sources of fluid intake to maintain accurate fluid balance records. Medications
administered through a gastrostomy tube contribute to the patient's overall fluid intake and must be included in the documentation.

D. Confirming that the nurse determined the amount of gastric residual is correct. This is a critical step to ensure that the patient is tolerating the feedings and to prevent complications such as
aspiration. Gastric residual volume can indicate if the patient's digestive system is processing the feeding appropriately.

E. Advising the nurse to use the plunger when giving medications is not necessary in this context. The use of a plunger can be appropriate in some situations, but the scenario does not provide enough information to suggest that the nurse had difficulty administering the medications that would require the use of a plunger. Additionally, using a plunger can increase the risk of tube
damage or patient discomfort.

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The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

Correct Answer is B

Explanation

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

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