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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Current vital signs are essential for assessing for neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications like haloperidol. Vital signs such as temperature, blood pressure, heart rate, and respiratory rate are crucial indicators of
NMS.
B. While monitoring white blood cell count may be important for detecting infections or adverse reactions to medications, it is not specific to assessing for NMS.
C. Monitoring 24-hour urinary output may be important for assessing renal function but is not specific to assessing for NMS.
D. Monitoring blood sugar levels may be important for clients with diabetes or those at risk of hyperglycemia due to medication effects, but it is not specific to assessing for NMS.
Correct Answer is B
Explanation
Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.
Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.
Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.
Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.
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