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 C
Explanation
The correct answer is choice C: Leave the room after offering to return to the client's room at a later time.
Choice A rationale:
Consulting with the charge nurse about implementing suicide precautions is not appropriate in this situation. The client has not expressed suicidal ideation or intent, and such an action could be invasive and distressing for the client.
Choice B rationale:
Sitting quietly in the client's room until the client is ready to verbalize his feelings might seem supportive, but it disregards the client's request for alone time. It's essential to respect the client's wishes and provide an opportunity for self-reflection and privacy.
Choice C rationale:
Leaving the room after offering to return to the client's room at a later time is the most appropriate action. The client has requested solitude, and respecting his autonomy is crucial in building trust and rapport.
Choice D rationale:
Notifying a member of the client's family of the need to come stay with the client is not necessary at this point. The client's desire for alone time does not indicate an immediate need for family support. The practical nurse should first respect the client's request and give him space to process the news. If the client later expresses a need for family support, appropriate actions can be taken accordingly.
Correct Answer is B
Explanation
The correct answer is choice B, Serum creatinine. Choice A rationale:
The white blood cell count (WBC) is an important parameter for assessing the body's immune response to infections. While it can provide valuable information about the presence of an infection, it is not directly related to nephrotoxicity. Therefore, it is not the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity.
Choice B rationale:
Serum creatinine is a crucial laboratory value to assess kidney function. It is a waste product that is filtered by the kidneys, and its level in the blood is a reliable indicator of kidney function. If the serum creatinine level is elevated, it suggests impaired kidney function, which can be a warning sign of nephrotoxicity. Reviewing the serum creatinine level before administering nephrotoxic antibiotics is essential to ensure that the client's kidneys are functioning adequately and to avoid potential harm.
Choice C rationale:
Hemoglobin and hematocrit are indicators of the client's red blood cell count and blood's oxygen-carrying capacity. While these values can provide information about the client's overall health status, they are not directly related to nephrotoxicity. Therefore, they are not the most important laboratory values to review in this particular scenario.
Choice D rationale:
Serum calcium levels are essential for assessing bone health, nerve function, and muscle contractions. However, they are not directly related to nephrotoxicity, and reviewing serum calcium levels alone would not provide sufficient information about kidney function. Hence, it is not the most critical value to review before administering nephrotoxic antibiotics
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