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 D

Explanation

A. Clients taking disulfiram must completely avoid alcohol, as even small amounts can cause severe reactions (e.g., nausea, vomiting, flushing, hypotension). There is no safe amount of alcohol to consume while on this medication.
B. Alcohol consumption must be completely avoided, not just limited, while taking disulfiram, as the drug works by causing an aversive reaction when alcohol is ingested.
C. Disulfiram should not be started immediately if alcohol is still in the system. It must be initiated at least 12–48 hours after the last drink to prevent severe reactions.
D. The client should begin taking disulfiram at least 48 hours after the last alcohol intake to reduce the risk of adverse effects. The medication is taken daily, and alcohol must be strictly avoided, including in hidden sources like mouthwash and cooking extracts.

A. Client claims that she was forced to participate in sexual intercourse. B. Client reported that she had sexual relations against her will. C. Client has been sexually assaulted. D. Client states, "My date raped me tonight."

Correct Answer is D

Explanation

Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.

Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.

Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.

Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.

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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

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

Correct Answer is D

Explanation

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

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The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?