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 A

Explanation

A. Obtain a capillary glucose level: The symptoms of jitteriness and tachypnea in a newborn could be indicative of hypoglycemia, so the first action should be to assess the glucose level to determine if hypoglycemia is the cause.

B. Feed 30 mL of 10% dextrose in water: While providing dextrose may be necessary if hypoglycemia is confirmed, assessing the glucose level should be done first to guide appropriate treatment.

C. Wrap tightly in a warm blanket: While keeping the newborn warm is important, it is not the first action to take in this scenario where the newborn is displaying signs of possible hypoglycemia.

D. Encourage the mother to breastfeeD Breastfeeding may help increase the newborn's glucose level, but the priority is to assess the glucose level first to determine if hypoglycemia is present.

A. Assign the UAP to provide care for another client and assume full care of the client. B. Review the need for the UAP to wear a face mask while in close contact with the client. C. Instruct the UAP to apply a fitted respirator mask before entering the client's room. D. Direct the UAP to notify the nurse of any changes in the client's respiratory status.

Correct Answer is B

Explanation

A. Assigning the UAP to another client does not address the need for proper infection control measures when assisting the client with influenza.

B. Wearing a face mask is essential to prevent the transmission of respiratory droplets during close contact with the client with influenza. Reviewing the importance of wearing a face mask reinforces infection control practices.

C. Applying a fitted respirator mask may not be necessary for routine care of a client with influenza and may not be readily available for UAP use.

D. While important, monitoring the client's respiratory status does not directly address the need for infection control measures to prevent the spread of influenza.

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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

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

Correct Answer is A

Explanation

The client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) don gloves and a gown to assist the client. Which action should the nurse take?

Correct Answer is B

Explanation

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