A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

The client will substitute a productive activity for mats by day one

The client will refrain from ritualistic behaviors during daylight hours.

The client will participate in the unit activities by day three

The Client will wake early enough to complete rituals prior to breakfast

Answer and Explanation

The Correct Answer is B

A. The client will substitute a productive activity for rituals by day one: This outcome may be challenging to achieve within the first day, and it is important to set realistic goals. Moreover, focusing on substituting a productive activity might not address the immediate need to reduce ritualistic behaviors.

B. The client will refrain from ritualistic behaviors during daylight hours: This is an appropriate initial outcome. It acknowledges the challenge of completely eliminating rituals but sets a realistic goal of refraining from these behaviors during daylight hours. This allows for gradual progress without setting unrealistic expectations.

C. The client will participate in unit activities by day three: While participation in unit activities is a positive goal, it may be too optimistic to expect this within the first three days, especially considering the severity of obsessive-compulsive disorder symptoms.

D. The client will wake early enough to complete rituals prior to breakfast: This goal does not promote a reduction in ritualistic behaviors; instead, it may reinforce and accommodate the rituals. The aim of treatment for obsessive-compulsive disorder is to reduce the impact of these rituals, not to support them.

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Correct Answer is A

Explanation

A. Self-destructive behavior despite alternative interventions: Mechanical restraints may be considered when a client poses an immediate risk of harm to themselves, and alternative interventions have been ineffective or are not feasible.

B. Discipline for throwing objects at staff: Mechanical restraints are not appropriate as a form of discipline. Restraints should only be used when there is an imminent risk of harm to the client or others.

C. Punishment for verbally abusing other clients: The use of restraints as a form of punishment is not ethical or appropriate. Restraints should be employed solely to prevent harm, not as a disciplinary measure.

D. Coercion to take prescribed medications: Coercion to take medications is not a valid reason for using mechanical restraints. Alternative approaches, such as therapeutic communication or discussing the need for medications with the client, should be explored.

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts B. Your child's hallucinations are caused by medication interactions C. your child has too little serotonin in the brain causing delusions and hallucinations D. your child's abnormal hormonal changes have precipitated auditory hallucinations

Correct Answer is A

Explanation

A. Your child has a chemical imbalance of the brain, which leads to altered thoughts: This is the correct answer. It acknowledges the role of a chemical imbalance in the brain contributing to altered thoughts and hallucinations in the context of schizophrenia.

B. Your child's hallucinations are caused by medication interactions: This explanation is not likely in this context. While medications can have side effects, command hallucinations in schizophrenia are primarily related to the underlying disorder.

C. Your child has too little serotonin in the brain causing delusions and hallucinations: While serotonin is involved in mood regulation, attributing hallucinations solely to low serotonin levels oversimplifies the complex neurobiology of schizophrenia.

D. Your child's abnormal hormonal changes have precipitated auditory hallucinations: Hormonal changes are not considered a primary cause of auditory hallucinations in schizophrenia. The emphasis is on neurobiological and genetic factors influencing brain function.

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A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

Correct Answer is A

Explanation

A 16-year-old client diagnosed with schizophrenia experiences command hallucinations to harm others. The clients parents ask a nurse. Where do the voices come from? Which is the appropriate nursing reply?

Correct Answer is A

Explanation

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A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization?

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