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A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
- A. Isolate the client for a period of time.
- B. Confront the client about the senseless nature of the repetitive behaviors.
- C. Plan the client's schedule to allow time for rituals.
- D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Correct Answer: C
Rationale: The correct answer is C: Plan the client's schedule to allow time for rituals. This is the most appropriate action as it acknowledges the client's need for engaging in compulsive behaviors while also structuring the time effectively. Isolating the client (Choice A) would be counterproductive, as social isolation can exacerbate OCD symptoms. Confronting the client (Choice B) may lead to increased anxiety and resistance. Setting strict limits (Choice D) can cause distress and potential non-compliance. The key is to support the client by incorporating their rituals into the schedule while working towards gradually reducing them in a therapeutic manner.
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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
- A. Talk to the nursing staff.
- B. Talk to the client and identify the specific limits that are required of the client's behavior.
- C. Discuss the problem in a community meeting with the other clients on the unit present.
- D. Escort the client to her room each time the nurse observes the client socializing with others.
Correct Answer: B
Rationale: The correct initial action for the nurse to take is choice B: Talk to the client and identify the specific limits that are required of the client's behavior. This option is the most appropriate because it directly addresses the client's behavior and sets clear expectations. By having a one-on-one conversation with the client, the nurse can establish boundaries and consequences for disruptive behavior, which may help modify the client's actions. Talking to the nursing staff (choice A) may be necessary later, but addressing the client directly is the first step. Discussing the problem in a community meeting (choice C) may embarrass the client and not address the behavior directly. Escorting the client to her room (choice D) does not address the underlying issue of lying and disruptive behavior.
A nurse is caring for a client who is hospitalized and says to the nurse, "My partner called and told me my boss hired someone to take my place." Which of the following responses should the nurse make?
- A. "You should call your boss and ask if you can have your job back."
- B. "I don't understand why your partner would upset you with news like that."
- C. "There really isn't much you can do about that until you are discharged."
- D. "You must feel very concerned and disappointed by that information."
Correct Answer: D
Rationale: Acknowledging the client’s emotions promotes therapeutic communication.
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. "The legal requirement for client confidentiality ceases if the client is deceased."
- B. "Staff members are required to divulge information to attorneys if they call for information."
- C. "Health care workers are not required to answer a court's requests for information about a client's disclosure."
- D. "Providers are required to warn individuals if the client threatens harm."
Correct Answer: D
Rationale: The correct answer is D because it refers to the duty to warn, which is a legal exception to client confidentiality. When a client poses a serious and imminent threat of harm to others, healthcare providers have a duty to warn those at risk. This exception prioritizes public safety over confidentiality.
Explanation of why other choices are incorrect:
A: Incorrect. Confidentiality typically extends even after a client's death to protect their privacy rights and maintain trust in healthcare providers.
B: Incorrect. Disclosing information to attorneys without client consent violates confidentiality unless required by law or court order.
C: Incorrect. Healthcare workers are generally required to comply with court requests for information unless protected by a legal privilege.
E, F, G: Not provided.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?
- A. Telling his parents that he doesn't want to talk about the suicide attempt.
- B. Stating that he wants to be with his peers more than with his parents.
- C. Preferring to eat his meals while watching TV.
- D. Planning to give his CD collection to his girlfriend.
Correct Answer: D
Rationale: The correct answer is D: Planning to give his CD collection to his girlfriend. This behavior indicates the adolescent is making future plans involving giving away possessions, which could be a sign of continued suicidal ideation. Giving away prized possessions is often seen as a way of saying goodbye or preparing for death. Choices A, B, and C do not necessarily indicate ongoing suicidal intent. A may suggest avoidance, B may indicate a desire for peer support, and C may be a personal preference. Therefore, D is the most concerning behavior that warrants immediate attention.