A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

stop the client in the hall and tell them that they must pace in the day room instead.

keep hands in pockets so as not to appear threatening.

speak softly and calmly,

offer the client a cup of coffee.

Answer and Explanation

The Correct Answer is C

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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Correct Answer is D

Explanation

a. "I'm afraid you would feel very guilty leaving your parents." This response assumes a negative outcome and does not encourage independent decision-making.
b. "Why would you want to leave a secure home?" This response discourages the client from considering independence and reinforces dependent behavior.
c. "It would be best to do that to increase independence." This statement provides advice rather than encouraging the client to explore their own feelings and options.
d. "Let's discuss and explore all of your options." This is correct because it encourages the client to consider various possibilities and promotes independent decision-making, which is essential for someone with dependent behaviors.

A. interrupt the handwashing and insist the client come to meals with everyone else. B. provide the client's meals later and after the other clients have eaten. C. notify the client when it is 30 minutes before the meal so they can begin their handwashing. D. allow the client to continue as is but provide them access to the kitchen.

Correct Answer is D

Explanation

a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.

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A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client exhibiting dependent behaviors says, "Do you think I should move from my parent's house and get a job?" Which nursing response is most appropriate?

Correct Answer is D

Explanation

A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:

Correct Answer is D

Explanation

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