A nurse is in the day room of an acute care mental health facility with a group of clients who are watching television.
Suddenly, one of the clients jumps up screaming and runs out of the room.
What should the nurse do next?
Ask the group what they think about the client’s behavior.
Stay with the group and ask another client to go and check on the situation.
Follow the client to determine the cause of the behavior.
Ignore the incident since it is an attention-seeking behavior.
The Correct Answer is C
Choice A rationale:
Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.
Choice B rationale:
Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.
Choice D rationale:
Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.
Choice C rationale:
Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:
Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.
Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.
Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.
Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.
Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.
Blurred vision and nausea are common early symptoms of lithium toxicity.
Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.
The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.
The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.
Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.
Choice A rationale:
Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.
It is important for the nurse to take more decisive action to prevent further toxicity.
Choice B rationale:
Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.
It is important for the nurse to take immediate action to protect the client's health.
Choice C rationale:
Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.
This is not a safe or appropriate action for the nurse to take in this situation.
Correct Answer is D
Explanation
The rationale for Choice A:
Limiting time for rituals to 30 minutes each day may not be effective and could potentially increase anxiety. Individuals with OCD often feel a strong compulsion to perform their rituals, and abruptly restricting their ability to do so can heighten distress and lead to increased attempts to engage in the rituals, even in a covert manner. This can create a cycle of anxiety and frustration.
Gradual exposure and response prevention (ERP) therapy is a more effective approach to reducing ritualistic behaviors. It involves gradually exposing the individual to anxiety-provoking stimuli while helping them to resist engaging in their compulsions. This process is done in a controlled and supportive environment, to help the individual learn to manage their anxiety and reduce their reliance on rituals.
Rationale for Choice B:
Providing a stimulating environment is not generally recommended for individuals with OCD. Excessive stimulation can exacerbate anxiety and trigger compulsive behaviors. A calmer and more structured environment is often more beneficial.
Individuals with OCD often thrive in environments that provide predictability and a sense of control. A structured schedule can help to reduce uncertainty and create a sense of order, which can in turn help to reduce anxiety and the urge to engage in compulsive behaviors. Rationale for Choice C:
Negative reinforcement is not an appropriate or effective intervention for OCD. It involves punishing or removing a desired stimulus in response to a behavior, with the aim of decreasing the likelihood of that behavior occurring again. However, this approach can be counterproductive in OCD, as it can increase anxiety and make the individual more likely to engage in their rituals in order to avoid the negative consequences.
Positive reinforcement, such as praise and encouragement, is more effective in promoting desired behaviors. This approach focuses on rewarding the individual for making progress in reducing their ritualistic behaviors, which can help to increase motivation and create a more positive and supportive environment for change.
Rationale for Choice D:
Providing a structured schedule of activities can be a very effective intervention for OCD. It can help to reduce anxiety, provide a sense of control, and minimize the time available for engaging in compulsive rituals.
A structured schedule can include a variety of activities, such as:
Mealtimes
Personal hygiene routines
Work or school activities
Leisure activities
Relaxation exercises
Social interactions
The schedule should be tailored to the individual's specific needs and preferences. It is important to ensure that the activities are enjoyable and meaningful to the individual, as this will increase their motivation to participate.
The nurse can work with the individual to develop a schedule that is realistic and achievable. The schedule should be reviewed and adjusted regularly as the individual makes progress.
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