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A client with obsessive-compulsive disorder (OCD) spends hours checking and rechecking the locks on the doors. What is the best nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Encourage the client to discuss the thoughts and feelings behind the behavior.
- C. Prevent the client from checking the locks to break the cycle.
- D. Schedule specific times for the client to check the locks.
Correct Answer: B
Rationale: The best nursing intervention for a client with OCD who spends excessive time checking locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can gain insight and work towards behavior modification. Choice A is incorrect because enabling the behavior does not address the underlying issues. Choice C is incorrect as it may lead to increased anxiety and distress. Choice D is incorrect as it does not address the root cause of the behavior.
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A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?
- A. Attempt to ask the client simple questions.
- B. Postpone the client interview until the next day.
- C. Ask another nurse to talk with the client.
- D. Document the client's paranoid behavior.
Correct Answer: A
Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.
A client with schizophrenia is being treated with clozapine (Clozaril). What laboratory test is most important for the nurse to monitor?
- A. Liver function tests
- B. Kidney function tests
- C. White blood cell count
- D. Blood glucose levels
Correct Answer: C
Rationale: The correct answer is C: White blood cell count. Clozapine can lead to agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count is crucial to detect this condition early. Choices A, B, and D are incorrect because while liver and kidney function tests are important in monitoring other aspects of health, the most critical concern with clozapine therapy is the risk of agranulocytosis, making monitoring white blood cell count the priority.
A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Schedule specific times for handwashing.
- C. Encourage the client to discuss the thoughts and feelings behind the behavior.
- D. Restrict the client's access to soap and water.
Correct Answer: C
Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.
A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?
- A. Calmly approach the client and remove the chair from the client.
- B. Obtain staff assistance to help diffuse the escalating situation.
- C. Offer feedback about the client's behavior.
- D. Summon the hospital security guards as a 'show of force.'
Correct Answer: B
Rationale: In a situation where a client is displaying aggressive behavior, the most important action for the nurse to implement is to obtain staff assistance to help diffuse the escalating situation. This approach ensures the safety of all individuals involved and prevents the situation from escalating further. Calmly approaching the client and removing the chair directly could agitate the client further and pose a risk to the nurse. Offering feedback about the client's behavior may not address the immediate safety concerns. Summoning hospital security guards as a 'show of force' should be a last resort after other de-escalation attempts have failed, as it may further provoke the client.
The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states 'I don't need to be here,' and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?
- A. Insight and judgment.
- B. Mood and affect.
- C. Remote memory.
- D. Level of concentration.
Correct Answer: A
Rationale: The correct answer is A: Insight and judgment. The client's statements indicate her lack of insight into her need for hospitalization ('I don't need to be here') and the presence of a delusion (believing that the TV talks to her). These statements reflect the client's insight into her condition and judgment. This information is crucial for assessing the client's understanding of her situation and decision-making capacity. Choice B, Mood and affect, focuses on the client's emotional state rather than her insight and judgment. Choice C, Remote memory, pertains to the ability to recall past events, which is not the primary focus of the client's statements. Choice D, Level of concentration, is not directly related to the client's statements about her need for hospitalization and the delusional belief about the TV.