Nokea
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
- A. Decrease anxiety
- B. Prevent aggressive and impulsive behaviors
- C. Manipulate others
- D. Decrease the time available for interaction with people
Correct Answer: A
Rationale: The correct answer is A: Decrease anxiety. The repetitive cleaning behavior in OCD is a manifestation of the client's attempt to reduce anxiety caused by intrusive thoughts or obsessions. This behavior provides temporary relief from anxiety by creating a sense of control. Choice B is incorrect because OCD cleaning behaviors are not primarily aimed at preventing aggressive or impulsive behaviors. Choice C is incorrect as the cleaning behavior is not typically a form of manipulation. Choice D is incorrect as the primary goal of the behavior is not to decrease interaction time but to manage anxiety.
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A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
- A. "Perhaps you could call your children to see how they are doing."
- B. "Don't worry. I'll take good care of your parent while you are gone."
- C. "You are feeling drawn in two separate directions."
- D. "There's nothing you can do here. You should go home to your children."
Correct Answer: C
Rationale: Rationale for Correct Answer C: The nurse should acknowledge the son's feelings of being torn between staying with his parent and going home to his children. This response demonstrates empathy and understanding of the son's emotional struggle, validating his concerns. By acknowledging his conflicting emotions, the nurse can help the son process his feelings and make a decision that aligns with his needs and responsibilities.
Summary of Incorrect Choices:
A: This response does not address the son's emotional conflict and does not offer support or validation.
B: This response focuses on the nurse's care for the parent, disregarding the son's emotional needs.
D: This response dismisses the son's concerns and suggests leaving without considering his emotional state or responsibilities.
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
- A. A private room in a quiet location on the unit
- B. A semiprivate room with a roommate who has similar symptoms
- C. A private room close to the nursing station
- D. A seclusion room until the client's activity level becomes more subdued
Correct Answer: C
Rationale: The correct answer is C: A private room close to the nursing station. This choice ensures the client's safety and allows for close monitoring by the nursing staff due to the increased risk of impulsive behaviors during the manic phase. A private room helps minimize distractions and stimuli that can exacerbate manic symptoms, while proximity to the nursing station enables quick intervention if needed.
Incorrect choices:
A: A private room in a quiet location on the unit - While privacy is important, a quiet location may not provide adequate supervision and support for a client in the manic phase.
B: A semiprivate room with a roommate who has similar symptoms - Sharing a room with someone exhibiting similar symptoms may lead to escalation of behaviors and lack of supervision.
D: A seclusion room until the client's activity level becomes more subdued - Seclusion should only be used as a last resort for safety concerns and is not appropriate for managing manic symptoms.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting and is now pacing up and down the corridors of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client helps provide support while allowing them to work through their anxiety.
A nurse is caring for an older adult client who had a cerebrovascular accident and has right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he did not insist that his mother live with him. Which of the following responses should the nurse make?
- A. "So, it seems that you feel responsible for what happened to your mother."
- B. "Your mother will be fine. You shouldn't worry so much."
- C. "Why do you blame yourself? You could not have prevented the stroke."
- D. "You are not responsible for your mother's stroke, but many people in your situation feel this way."
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
A is the correct response because it acknowledges the son's feelings without dismissing or invalidating them. It shows empathy and understanding towards his guilt, opening up a conversation for further exploration of his emotions. It reflects active listening and validates his concerns.
Summary of Incorrect Choices:
B: This response minimizes the son's feelings and does not address his sense of guilt, which can further exacerbate his emotional distress.
C: While this response provides reassurance, it does not address the son's feelings of guilt and may come off as dismissive.
D: This response acknowledges the son's feelings but does not directly validate his sense of responsibility, missing an opportunity for therapeutic communication.
A nurse manager is providing staff education about working with clients who have a history of anger and aggression. Which of the following information should the nurse include in the teaching? (Select all that apply.)
- A. Avoid wearing necklaces during client care.
- B. Know the layout of the facility.
- C. Stand directly in front of the client when talking.
- D. Bring security with you for all client interactions.
- E. Provide immediate verbal feedback for escalating behavior.
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. A: Wearing necklaces can be used as a weapon or trigger aggressive behavior. B: Knowing the facility layout helps in planning safe exits during an escalating situation. E: Providing immediate verbal feedback can help de-escalate aggressive behavior. C: Standing directly in front of the client can be confrontational. D: Bringing security for all interactions may escalate tension unnecessarily.