A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder.

The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

"Ask a family member to check the locks for you at night."

"Keep a journal of how often you check the locks each night."

"Focus on abdominal breathing whenever you go to check the locks."

"Snap a rubber band on your wrist when you think about checking the locks."

Answer and Explanation

The Correct Answer is D

A.   Asking a family member to check the locks for the client may alleviate immediate anxiety but does not address the underlying obsessive-compulsive behavior or provide coping mechanisms for the client to manage their symptoms independently.
B.   Keeping a journal of checking behaviors may be part of exposure and response prevention therapy but does not directly address the intrusive thoughts associated with obsessive- compulsive disorder in the moment.
C.   Focusing on abdominal breathing is a relaxation technique that may help reduce overall anxiety but does not specifically target the intrusive thoughts associated with obsessive- compulsive disorder.
D.   Using a rubber band to snap on the wrist when the client thinks about checking the locks is a form of aversion therapy, which is a component of thought stopping technique. This technique helps interrupt and redirect the obsessive thoughts, promoting awareness and control over compulsive behaviors.

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Correct Answer is ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

A. A client who has anorexia nervosa and expresses a fear of gaining weight B. A client who has bipolar disorder and is exhibiting poor impulse control C. A client who has schizophrenia and is exhibiting clang associations in their speech D. A client who has Alzheimer's disease and is having difficulty remember names of family members

Correct Answer is B

Explanation

A. While a client with anorexia nervosa may require close monitoring and support, expressing a fear of gaining weight does not necessarily indicate an immediate safety concern that requires an update to the plan of care.

B. Bipolar disorder can involve manic episodes characterized by impulsivity and risk-taking behaviors. Exhibiting poor impulse control indicates a potential safety concern that requires an update to the plan of care to ensure the client's safety and the safety of others.
C. Clang associations in speech are a symptom of disorganized thinking commonly seen in schizophrenia. While it may indicate a need for intervention, it does not necessarily require an immediate update to the plan of care for safety reasons.
D. Difficulty remembering names of family members is a symptom of Alzheimer's disease and may require ongoing support and management but does not present an immediate safety concern that requires an update to the plan of care.

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A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

Correct Answer is B

Explanation

A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

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A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?

A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder.

The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?