Obsessive Compulsive Disorder
A nurse is caring for a client with OCD who engages in repeated handwashing rituals. Which of the following nursing interventions is most appropriate?
A. Provide immediate redirection when the client starts handwashing.
B. Allow the client to complete the ritual initially while gradually setting limits.
C. Remove soap and water to prevent the ritual behavior.
D. Encourage the client to replace handwashing with deep breathing exercises immediately.
Correct Answer: B. Allow the client to complete the ritual initially while gradually setting limits.
Rationale: Abruptly stopping ritualistic behavior can increase anxiety. Initially allowing the ritual while gradually introducing limits and alternative coping strategies is a more therapeutic approach. This method provides comfort while working toward behavior modification.
A nurse is assessing a client with major depressive disorder. Which of the following symptoms should the nurse expect to observe?
A. Pressured speech and flight of ideas
B. Anhedonia and sleep disturbances
C. Increased self-esteem and impulsivity
D. Hallucinations and delusions
Correct Answer: B. Anhedonia and sleep disturbances.
Rationale: Anhedonia, or a loss of interest or pleasure in previously enjoyed activities, is a hallmark symptom of MDD. Sleep disturbances, such as insomnia or hypersomnia, are also common. The other options are more characteristic of manic episodes or psychotic disorders, not MDD.
A nurse is caring for a client with moderate anxiety. Which of the following behaviors should the nurse expect?
A. The client is completely calm and focused on tasks.
B. The client has narrowed perception and selective attention.
C. The client is unable to process environmental stimuli.
D. The client displays disorganized behavior and loss of reality.
Correct Answer: B. The client has narrowed perception and selective attention.
Rationale: Moderate anxiety involves a narrowed focus of attention and reduced ability to perceive peripheral stimuli. The client may need help focusing but can still follow directions. The other options describe mild, severe, or panic-level anxiety, respectively.
Which of the following safety precautions should the nurse recommend to the parents of an adolescent taking trazodone?
A. "Keep the medication in an unlocked cabinet for easy access."
B. "Monitor for signs of increased depression or suicidal thoughts."
C. "Encourage high-intensity exercise immediately after taking trazodone."
D. "Allow the adolescent to make dose adjustments if needed."
Correct Answer: B. "Monitor for signs of increased depression or suicidal thoughts."
Rationale: Adolescents taking antidepressants, including trazodone, should be closely monitored for worsening depression or emergence of suicidal thoughts, particularly when starting the medication or adjusting the dose. The other options could compromise safety, as medication should be stored securely, exercise should be appropriate to the individual’s condition, and only a healthcare provider should adjust dosages.
A nurse is caring for a client who is taking a selective serotonin reuptake inhibitor (SSRI) and a monoamine oxidase inhibitor (MAOI) for depression. The client suddenly develops agitation, hyperreflexia, and a fever. Which of the following actions should the nurse take first?
A. Administer a dose of lorazepam to decrease agitation.
B. Withhold the client’s medications and notify the healthcare provider.
C. Place the client in a cooling blanket to reduce fever.
D. Assess the client’s blood pressure and heart rate.
Correct Answer: B. Withhold the client’s medications and notify the healthcare provider.
Rationale:
The combination of an SSRI and an MAOI increases the risk of serotonin syndrome, a potentially life-threatening condition. The nurse should immediately withhold the medications and notify the healthcare provider. The symptoms of serotonin syndrome (agitation, hyperreflexia, fever) suggest this condition, and prompt medical intervention is needed. While other actions such as cooling the client may be part of the treatment, withholding the medications is the most immediate and critical step.
When developing a plan of care for a client with OCD, which goal is most appropriate for the early stages of treatment?
A. The client will completely eliminate ritualistic behaviors within 1 week.
B. The client will verbalize feelings of anxiety that trigger compulsive behaviors.
C. The client will avoid situations that trigger compulsions.
D. The client will perform rituals only when alone in their room.
Correct Answer: B. The client will verbalize feelings of anxiety that trigger compulsive behaviors.
Rationale: Early treatment focuses on helping the client recognize and verbalize the anxiety that precedes compulsive behaviors. This insight is essential for developing healthier coping strategies. Immediate elimination of rituals is unrealistic and may increase distress.
Which of the following is a cognitive symptom of major depressive disorder that a nurse might observe?
A. Increased appetite and weight gain
B. Persistent guilt and feelings of worthlessness
C. Excessive energy and restlessness
D. Grandiose thoughts and distractibility
Correct Answer: B. Persistent guilt and feelings of worthlessness.
Rationale: Cognitive symptoms of MDD often include persistent negative thoughts, feelings of excessive guilt, and a lack of self-worth. These symptoms contribute to the pervasive sadness and low mood associated with depression. The other options suggest manic or hypomanic behaviors.
A client experiencing severe anxiety is pacing rapidly and breathing heavily. Which intervention should the nurse implement first?
A. Encourage the client to discuss their feelings.
B. Offer detailed instructions on relaxation techniques.
C. Use a calm voice to offer a simple, repetitive statement.
D. Provide educational materials about anxiety management.
Correct Answer: C. Use a calm voice to offer a simple, repetitive statement.
Rationale: During severe anxiety, a client's ability to process information is limited. Using simple, clear communication helps reduce anxiety and provides a sense of safety. Complex instructions or education should be deferred until the anxiety level decreases.
A nurse is discussing potential side effects of trazodone with an adolescent client. Which of the following statements by the client indicates a need for further teaching?
A. "I might feel a bit sleepy after taking trazodone."
B. "If I feel better, I can stop taking trazodone without telling my doctor."
C. "I should get up slowly to avoid feeling dizzy."
D. "I need to let my provider know if I develop any unusual bruising."
Correct Answer: B. "If I feel better, I can stop taking trazodone without telling my doctor."
Rationale: Trazodone should not be discontinued abruptly, as this can lead to withdrawal symptoms and potential relapse of depression. The provider should always guide medication discontinuation. The other statements reflect appropriate understanding of the medication's side effects and precautions.
Which of the following medications increases a client's risk for serotonin syndrome when combined with an SSRI?
A. Ibuprofen
B. St. John's wort
C. Metformin
D. Lisinopril
Correct Answer: B. St. John's wort
Rationale:
St. John's wort is an herbal supplement that has serotonergic effects. When combined with an SSRI, it can increase serotonin levels excessively, raising the risk for serotonin syndrome. Ibuprofen, metformin, and lisinopril do not have serotonergic effects and are not associated with serotonin syndrome when taken with SSRIs.
Which of the following is a priority nursing intervention for a client with OCD who is experiencing severe anxiety?
A. Encourage the client to avoid all compulsive behaviors.
B. Instruct the client to suppress obsessive thoughts.
C. Provide a structured schedule that includes time for rituals.
D. Isolate the client until the anxiety subsides.
Correct Answer: C. Provide a structured schedule that includes time for rituals.
Rationale: Creating a structured schedule with allocated time for rituals helps the client feel a sense of control and gradually reduces the need for compulsions. This approach also helps the client transition to healthier coping mechanisms over time.
A nurse is caring for a client with major depressive disorder who presents with psychomotor retardation. Which of the following describes this symptom?
A. Involuntary muscle movements and tics
B. Slowed physical movements and speech
C. Repetitive, purposeless movements
D. Rapid and excessive talking
Correct Answer: B. Slowed physical movements and speech.
Rationale: Psychomotor retardation is a classic symptom of MDD, characterized by a noticeable slowing of physical and mental processes. Clients may exhibit delayed responses, a reduction in spontaneous movement, and slow speech.
A nurse is assessing a client who is experiencing panic-level anxiety. Which of the following manifestations should the nurse expect?
A. Increased problem-solving ability
B. Hypervigilance and selective inattention
C. Distorted perception and sense of impending doom
D. Logical thought processes and clear communication
Correct Answer: C. Distorted perception and sense of impending doom.
Rationale: Panic-level anxiety is the most severe form of anxiety, where the individual may lose touch with reality, experience extreme fear, and display disorganized behavior. The other options describe lower levels of anxiety.
A nurse is caring for a client with schizophrenia who is prescribed alprazolam for generalized anxiety disorder. The client asks, "How will I know if the medication is working?" The nurse should provide which of the following responses?
A. "You will notice a significant increase in your energy levels and alertness."
B. "You should feel more relaxed and less anxious."
C. "Your mood should improve significantly within a few days."
D. "You may feel more focused and less distracted."
Correct Answer: B. "You should feel more relaxed and less anxious."
Rationale: Alprazolam is primarily used to manage anxiety and should help the client feel more relaxed and less anxious. It is not intended to significantly improve energy, mood, or concentration, which are more related to other psychiatric medications (e.g., antidepressants or antipsychotics).
A nurse is assessing a client who recently started taking lamotrigine for bipolar disorder. Which of the following findings should alert the nurse to the possibility of Stevens-Johnson syndrome (SJS)?
A. Mild gastrointestinal discomfort and diarrhea
B. A widespread, painful rash with blistering and peeling skin
C. Hypertension and tachycardia
D. Muscle rigidity and hyperreflexia
Correct Answer: B. A widespread, painful rash with blistering and peeling skin
Rationale:
Stevens-Johnson syndrome (SJS) is a rare but severe disorder that affects the skin and mucous membranes, often triggered by medications such as lamotrigine, carbamazepine, and certain antibiotics. It presents with flu-like symptoms followed by a painful rash, blistering, and widespread skin detachment, resembling a severe burn.
A client with OCD asks the nurse why they are allowed to continue their rituals in the hospital. Which of the following is the best response by the nurse?
A. "Stopping the rituals immediately will reduce your anxiety quickly."
B. "Your rituals are allowed initially to help manage your anxiety."
C. "We want to see how long you can go without doing your rituals."
D. "The rituals are not a problem as long as they do not harm anyone."
Correct Answer: B. "Your rituals are allowed initially to help manage your anxiety."
Rationale: This therapeutic response provides validation and education. Allowing rituals initially helps manage anxiety while establishing trust. Over time, the focus will shift to introducing coping strategies to replace rituals.
A nurse is reviewing the medical record of a client with major depressive disorder. Which of the following findings should the nurse recognize as a vegetative symptom of depression?
A. Poor concentration and memory impairment
B. Changes in bowel habits and appetite
C. Feelings of hopelessness and sadness
D. Engaging in self-harm behaviors
Correct Answer: B. Changes in bowel habits and appetite.
Rationale: Vegetative symptoms are physical manifestations of depression that affect basic bodily functions. These include changes in sleep, appetite, bowel habits, energy levels, and sexual function. The other options describe emotional or cognitive symptoms rather than vegetative ones.
Which intervention is most appropriate for a client with mild anxiety?
A. Encourage problem-solving and exploring coping strategies.
B. Use a firm tone to direct the client's actions.
C. Limit the client's choices to reduce stress.
D. Avoid discussing the source of the anxiety.
Correct Answer: A. Encourage problem-solving and exploring coping strategies.
Rationale: Mild anxiety can be beneficial, enhancing the client's ability to think and problem-solve. The nurse should support this process by encouraging the client to discuss their feelings and explore effective coping mechanisms.
A nurse is caring for a client who is taking bupropion and has a history of smoking. Which of the following is the most appropriate nursing intervention?
A. Instruct the client to stop smoking immediately.
B. Monitor the client for symptoms of nicotine withdrawal.
C. Advise the client to increase their nicotine intake while on bupropion.
D. Recommend the client continue smoking as usual while on bupropion.
Correct Answer: B. Monitor the client for symptoms of nicotine withdrawal.
Rationale: Bupropion is sometimes used as part of smoking cessation therapy because it can help reduce cravings and withdrawal symptoms. If the client is smoking while on bupropion, the nurse should be aware that nicotine withdrawal symptoms may occur if the client attempts to quit. Monitoring for withdrawal symptoms is important to help manage this process. The nurse should not instruct the client to stop smoking immediately unless it aligns with a planned smoking cessation strategy.
A nurse is assessing a client who recently started taking fluoxetine for depression. Which of the following findings should alert the nurse to the potential development of Stevens-Johnson syndrome (SJS)?
A. A red, blistering rash with peeling skin
B. Weight gain and increased appetite
C. Mild headache and drowsiness
D. Constipation and dry mouth
Correct Answer: A. A red, blistering rash with peeling skin
Rationale:
While Stevens-Johnson syndrome (SJS) is a rare side effect of fluoxetine, it is a severe condition characterized by a painful rash, blistering, peeling skin, and mucosal involvement. It often starts with flu-like symptoms, followed by the skin reaction.
If SJS is suspected, the medication should be discontinued immediately, and the client should receive urgent medical attention, often requiring hospitalization.
Which of the following techniques should the nurse use to help a client with OCD reduce ritualistic behavior over time?
A. Offer positive reinforcement when the client avoids rituals.
B. Implement strict consequences for engaging in rituals.
C. Suggest distraction techniques when the urge to perform rituals arises.
D. Increase the frequency of rituals to decrease anxiety.
Correct Answer: C. Suggest distraction techniques when the urge to perform rituals arises.
Rationale: Distraction techniques, such as engaging in a different activity, can help redirect focus away from compulsions. Over time, this approach can reduce the frequency of rituals by promoting alternative coping mechanisms.
When caring for a client with major depressive disorder, which intervention should the nurse include in the plan of care?
A. Encourage isolation to prevent overstimulation.
B. Promote a structured daily routine with achievable activities.
C. Avoid discussing the client's feelings to prevent distress.
D. Offer large, challenging tasks to boost confidence.
Correct Answer: B. Promote a structured daily routine with achievable activities.
Rationale: Establishing a routine with small, achievable goals can help clients with depression regain a sense of control and accomplishment. It also reduces the risk of overwhelming the client. Isolation and avoidance of feelings can worsen depression, while tasks that are too challenging can lead to frustration
A nurse is teaching a client with generalized anxiety disorder (GAD) about relaxation techniques. Which of the following statements indicates a need for further teaching?
A. "I will practice deep breathing exercises when I feel anxious."
B. "Using guided imagery might help me relax."
C. "I should avoid using relaxation techniques during an anxiety attack."
D. "Progressive muscle relaxation can help reduce my tension."
Correct Answer: C. "I should avoid using relaxation techniques during an anxiety attack."
Rationale: Relaxation techniques, such as deep breathing, guided imagery, and progressive muscle relaxation, are effective for managing anxiety at any level. The statement in option C indicates a misunderstanding of when to use these techniques and requires further education.
Which of the following items in the client’s medical record indicate that they are a candidate for electroconvulsive therapy (ECT)?
A. The client has a history of multiple suicide attempts and is severely depressed despite medication trials.
B. The client has a mild form of depression that has improved with psychotherapy alone.
C. The client has a history of mild hypertension and is responding well to anti-hypertensive therapy.
D. The client has chronic anxiety that is controlled with medications.
Correct Answer: A. The client has a history of multiple suicide attempts and is severely depressed despite medication trials.
Rationale:
Electroconvulsive therapy (ECT) is typically considered for clients who have severe, treatment-resistant depression, particularly those who have not responded to multiple medication trials or psychotherapy, or in cases where there is a risk of suicide. A history of multiple suicide attempts and severe depression, especially when medications have not been effective, makes this client a candidate for ECT.
Options B, C, and D are not appropriate indicators for ECT. Mild depression or controlled chronic anxiety typically does not require ECT, and mild hypertension controlled by medication does not indicate the need for this intervention. ECT is generally reserved for severe psychiatric conditions that are not responsive to other treatments.
DAILY DOUBLE!
A nurse is caring for a client who has post-traumatic stress disorder (PTSD) following a car accident. Which of the following statements by the client demonstrates the use of an adaptive defense mechanism?
A. "I avoid driving and refuse to talk about the accident."
B. "I started volunteering at a trauma support group to help others."
C. "I drink alcohol every night to help me forget about the accident."
D. "I get angry at my family when they ask me how I'm feeling."
Correct Answer: B. "I started volunteering at a trauma support group to help others."
Rationale:
Volunteering to support others who have experienced trauma is an example of altruism, an adaptive defense mechanism. This mechanism involves channeling distressing feelings into positive actions that benefit others, which can also promote the client's own healing process.
Adaptive defense mechanisms help clients cope with PTSD symptoms in a healthy and constructive way, contributing to emotional resilience and recovery.
Would you like more questions on defense mechanisms, PTSD, or mental health nursing interventions?