A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Determine the type and size of the locks.

Plan a list of activities to be carried out daily.

Discuss checking the time frequently.

Ask the client why the locks are checked so frequently.

Answer and Explanation

The Correct Answer is B

- Choice A Rationale: Determining the type and size of the locks does not address the client's anxiety or the behavior that is impacting their daily functioning. This action might inadvertently reinforce the client's focus on the locks rather than addressing the underlying issue.
- Choice B Rationale: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on the day's tasks and can provide a sense of control and accomplishment.
- Choice C Rationale: Discussing checking the time frequently does not directly address the client's repetitive behavior or the associated anxiety. While time management may be part of a broader treatment plan, it is not the most immediate action the nurse should take.
- Choice D Rationale: Ask the client why the locks are checked so frequently is not therapeutic and may put the client on the defensive. Clients with obsessive-compulsive behaviors often cannot explain why they perform rituals, as the behavior is driven by anxiety rather than logic. Asking "why" may increase frustration without helping to address the behavior.

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Correct Answer is B

Explanation

Rationale:
A. While participation in therapy is important, the primary focus should be on equipping the client with effective coping strategies to manage her anxiety.
B. This outcome directly addresses the client's maladaptive coping mechanism (scratching her wrists) by aiming to replace it with healthier coping strategies.
C. Learning relaxation techniques is beneficial, but it may not address the underlying issue of maladaptive coping behaviors like wrist scratching.
D. Taking antianxiety medications as prescribed is important for managing symptoms, but it does not directly address the client's maladaptive coping behavior or teach alternative coping strategies.

A. Ask the client to describe and identify the source of the feelings. B. Provide education about ways to cope with anxiety. C. Assist the client with relaxation techniques in the group. D. Escort the client from the group to reduce stimuli.

Correct Answer is D

Explanation

A. Asking the client to describe and identify feelings is more appropriate for a client with mild to moderate anxiety, not severe anxiety.
B. Providing education is ineffective during severe anxiety because the client is unable to process new information.
C. Relaxation techniques are difficult for a client to use during severe anxiety due to impaired concentration and focus.
D. Reducing environmental stimuli by escorting the client from the group is the best intervention for severe anxiety, as it helps the client regain control and lowers anxiety levels.

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A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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