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","C","D","E"]

Explanation

A. Advising the nurse to use the plunger when giving medications is not recommended as it can create too much pressure and potentially damage the gastrostomy tube or cause discomfort to the patient. It's important to allow the medication to flow by gravity to prevent these issues.

B. Encouraging the nurse to flush the tube with more water is correct because it helps to ensure that the medication is cleared from the tube and reduces the risk of clogging. Flushing with water also helps to maintain hydration for the patient.

C. Confirming that the nurse determined the amount of gastric residual is correct because it is essential to check for any undigested food or medication in the stomach before administering more. This helps to prevent aspiration and other complications.

D. Instructing the nurse to administer each medication separately is correct. This practice
prevents drug interactions within the tube and ensures that each medication is given correctly and has the intended effect.

E. Adding the liquid volumes when documenting fluid intake is correct because all fluids
administered, including medications, should be accounted for in the patient's fluid balance. This is crucial for monitoring and managing the patient's hydration status and overall health.

A. 18% B. 36% C. 4% D. 09%

Correct Answer is B

Explanation

A. 18%: This would be the correct percentage for one leg only.

B. 36%: According to the Rule of Nines in burn assessment, each leg (including the foot) accounts for 18% of the body surface area. Since both lower extremities are affected, it totals 36% body surface area.

C. 4%: This percentage is too low for the described injury.

D. 09%: This would not be enough even for one leg, as each leg is 18%.

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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

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

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

Explanation

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED with full thickness burns to all surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

Correct Answer is B

Explanation

Which environmental factor is most significant when planning care for a client with osteomalacia?

A client with obstructive sleep apnea (OSA ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5mg/kg/day subcutaneously. The medication is available in 120 mg/0.8 ml. prefiled syringe. How many ml. should the nurse administer? (Enter numerical value only)

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)