A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
Ask the client why she checks the locks.
Determine the type and size of the locks.
Discuss checking the time frequently.
Plan a list of activities to be carried out daily.
The Correct Answer is D
A. "Ask the client why she checks the locks."
Asking "why" questions may put the client on the defensive and does not effectively address the compulsive behavior. Clients with obsessive-compulsive disorder (OCD) often do not have a logical explanation for their compulsions.
B. "Determine the type and size of the locks."
This action does not address the client’s compulsive behavior and is not relevant to the nursing intervention. The focus should be on reducing the compulsive behavior rather than assessing the locks themselves.
C. "Discuss checking the time frequently."
This response does not directly address the client’s compulsive checking behavior. Instead, structured interventions that promote time management and coping strategies should be implemented.
D. "Plan a list of activities to be carried out daily."
Providing a structured daily schedule can help redirect the client’s focus away from compulsive behaviors and toward productive activities. A schedule can reduce anxiety and limit the time available for compulsions, promoting better functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Restricting visitors to family members only may not necessarily be a beneficial intervention and could potentially isolate the client further, which may not be in their best interest.
Choice B rationale:
Discussing the client's suicide plan is essential to assess the level of risk and develop strategies to keep the client safe. It allows the healthcare team to understand the severity of the client's depressive symptoms and potential suicidal ideation.
Choice C rationale:
Limiting the time allowed to play video games may be a consideration in a broader plan of care, but it is not a primary intervention for addressing depression in adolescents. The focus should be on safety, communication, and building a therapeutic relationship.
Choice D rationale:
Encouraging the client to discuss thoughts and feelings about wanting to die is crucial for therapeutic communication and assessment. It provides an opportunity for the client to express their emotions and allows for intervention and support.
Choice E rationale:
Reinforcing statements regarding a will to live and realistic plans for the future is important for building hope and motivation in the client. It can be part of a positive, strengths-based approach to treatment.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.
Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.
Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.
Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.
Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.
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