Extract:

Question 1 of 5

A nurse is planning care for a client who has dementia and exhibits wandering behavior. Which of the following interventions should the nurse include?

A. Restrain the client to prevent wandering.B. Place the client in a room near the nurse’s station.C. Encourage the client to participate in group activities.D. Install an alarm system on doors.

Correct Answer: B,D

Rationale: A room near the nurse’s station allows monitoring, and door alarms enhance safety without restraints, supporting dementia care principles.

Question 2 of 5

A nurse is discussing obsessive-compulsive disorder (OCD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the underlying reason clients with OCD perform ritualistic behaviors?

A. The ritualistic behavior temporarily relieves anxiety.B. The ritualistic behavior provides sexual satisfaction.C. The client performs ritualistic behavior to decrease feelings of shame.D. The client performs ritualistic behavior to boost self-esteem.

Correct Answer: A

Rationale: Ritualistic behaviors in OCD temporarily relieve anxiety caused by intrusive thoughts, forming a cycle of obsessions and compulsions, as supported by research on anxiety reduction.

Question 3 of 5

A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

A. Protecting the client from injuryB. Identifying the client's coping skillsC. Ensuring that the client feels safeD. Determining the cause of the client's anxiety.

Correct Answer: A

Rationale: Protecting the client from injury addresses the imminent risk of harm due to impaired decision-making and physiological agitation in acute anxiety, prioritizing safety above other interventions.

Question 4 of 5

A nurse is teaching a client who has a new prescription for diazepam. Which of the following instructions should the nurse include?

A. Avoid drinking alcohol while taking this medication.B. Stop taking the medication if you feel drowsy.C. Increase your dose if you feel anxious.D. Take this medication with a high-fat meal.

Correct Answer: A

Rationale: Alcohol potentiates diazepam’s CNS depression, increasing risks like sedation or respiratory issues, making avoidance critical.

Question 5 of 5

A nurse in the emergency department is caring for a 14-year-old who has anorexia nervosa. Which of the following 5 assessment findings require immediate follow-up?

A. Phosphate levelB. Capillary refillC. Sodium levelD. Magnesium levelE. Glucose level.

Correct Answer: A,B,C,D,E

Rationale: Phosphate, sodium, magnesium, and glucose imbalances, plus delayed capillary refill, signal severe malnutrition risks in anorexia nervosa, requiring urgent attention.