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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?
- A. Keep a journal of how often you check the locks each night
- B. Snap a rubber band on your wrist when you think about checking the locks
- C. Ask a family member to check the lock for you at night
- D. Focus on abdominal breathing whenever you go to check the locks
Correct Answer: B
Rationale: The correct answer is B: Snap a rubber band on your wrist when you think about checking the locks. This is an effective use of thought stopping technique as it creates a physical distraction and discomfort when the client has obsessive thoughts. It helps interrupt the pattern of behavior and redirects the client's focus away from the compulsion. Keeping a journal (A) may increase anxiety and reinforce the behavior. Asking a family member to check the lock (C) doesn't address the client's need to manage their own thoughts and behaviors. Focusing on abdominal breathing (D) may be a relaxation technique but doesn't directly address the obsessive thoughts.
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A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following should the nurse expect?
- A. Self-mutilation
- B. Pacing back and forth
- C. Preoccupation with details
- D. Disorganized speech
Correct Answer: A
Rationale: The correct answer is A: Self-mutilation. Individuals with borderline personality disorder often engage in self-harming behaviors as a way to cope with intense emotions or distress. This behavior is a common manifestation of the disorder and requires careful monitoring and intervention by the nurse.
Incorrect Choices:
B: Pacing back and forth - This behavior is more commonly associated with anxiety or agitation rather than specifically with borderline personality disorder.
C: Preoccupation with details - While individuals with borderline personality disorder may display perfectionistic tendencies, preoccupation with details is not a defining characteristic of the disorder.
D: Disorganized speech - Disorganized speech is more commonly seen in conditions such as schizophrenia, rather than borderline personality disorder.
A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.
A nurse is caring for a client who has major depressive disorder. After discussing the treatment with his partner, the client verbally agrees to electroconvulsive therapy (ECT) but will not sign the consent form. Which of the following actions should the nurse take?
- A. Request that the client’s partner sign the consent form
- B. Cancel the scheduled ECT procedure
- C. Proceed with the preparation for ECT based on implied consent
- D. Inform the client about the risks of refusing the ECT
Correct Answer: B
Rationale: The correct answer is B: Cancel the scheduled ECT procedure. The nurse must prioritize the autonomy and right to informed consent of the client. Since the client has verbally agreed but will not sign the consent form, it indicates uncertainty or potential coercion. Proceeding without proper documentation could lead to legal and ethical issues. Requesting the partner to sign (A) may not be ethically sound without the client's explicit consent. Proceeding based on implied consent (C) is risky and violates the client's autonomy. Informing the client about risks (D) is important but should not override the need for proper consent. Cancelling the procedure allows time for further discussion and ensures the client's best interest.
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
A nurse is providing teaching to a client who has obsessive-compulsive disorder and engages in excessive handwashing. Which of the following instructions should the nurse include?
- A. Encourage the client to stop washing hands
- B. Allow additional time for rituals
- C. Limit ritual behaviors immediately
- D. Ignore the compulsions
Correct Answer: B
Rationale: The correct answer is B: Allow additional time for rituals. This is because abruptly stopping the handwashing rituals can lead to increased anxiety and distress for the client. Allowing additional time for rituals can help the client feel more in control and gradually work towards reducing the behavior. Encouraging the client to stop washing hands (A) abruptly can be counterproductive. Limiting ritual behaviors immediately (C) can also increase anxiety. Ignoring the compulsions (D) may worsen the condition.