A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not understand how awful it is. I am a burden to my family because I cannot hold a job. I do not know how much longer I can live this way." Which information is most important for the practical nurse (PN) to ask in response to the client's statements?
Question about which rituals are most often used to reduce anxiety.
Ask if the obsessions and compulsions interfere with sleep.
Inquire if the distress could lead to considering suicide as an option.
Determine what makes the client think people are laughing.
The Correct Answer is C
This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.
A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.
B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.
D. Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D - Bilateral lung sounds.
Choice A rationale:
Heart sounds. While assessing heart sounds is crucial, the question specifically mentions complications of left-sided heart failure, which primarily affects the lungs. Therefore, assessing lung sounds is a higher priority in this situation.
Choice B rationale:
Mood and affect. While assessing the client's mood and affect is important for holistic care, it is not the most critical assessment to implement first in the case of left-sided heart failure complications.
Choice C rationale:
Chest pain. Although chest pain may be a symptom of left-sided heart failure complications, assessing bilateral lung sounds takes precedence as it directly relates to the client's respiratory status.
Choice D rationale:
Bilateral lung sounds. In left-sided heart failure, fluid can accumulate in the lungs, leading to pulmonary congestion and impaired gas exchange. Therefore, assessing lung sounds helps identify any respiratory distress early on, allowing prompt intervention and prevention of further complications.
Correct Answer is C
Explanation
The correct answer is choiceC. Health care proxy documentation.
Choice A rationale:
The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.
Choice B rationale:
While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.
Choice C rationale:
Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves.This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.
Choice D rationale:
The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation.This information is not as immediately critical as the health care proxy documentation during the admission assessment.
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