Nokea
How should a nurse address compulsive behaviors in a newly admitted client with OCD?
- A. Isolate the client
- B. Confront the client about the behavior
- C. Encourage participation in group activities
- D. Set strict limits on behaviors
- E. Allow additional time for rituals
Correct Answer: D
Rationale: Correct Answer: D. Set strict limits on behaviors
Rationale:
1. Setting strict limits helps establish boundaries and structure for the client.
2. It assists in reducing compulsive behaviors by providing clear guidelines.
3. It promotes a sense of control and safety for the client.
4. Allows for gradual exposure and response prevention therapy.
Summary:
A: Isolating the client can exacerbate feelings of loneliness and increase anxiety.
B: Confrontation may trigger defensiveness and hinder therapeutic rapport.
C: While group activities can be beneficial, they may not directly address the compulsive behaviors.
E: Allowing additional time for rituals reinforces maladaptive behaviors.
You may also like to solve these questions
Which intervention should a nurse prioritize when caring for a client with alcohol use disorder?
- A. Helping the client identify positive personality traits
- B. Providing adequate hydration and rest
- C. Confronting denial and defense mechanisms
- D. Educating the client about alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing adequate hydration and rest. This intervention is crucial because individuals with alcohol use disorder often experience dehydration and fatigue due to excessive alcohol consumption. Hydration helps to flush out toxins and restore electrolyte balance, while rest supports physical and mental recovery. Helping the client identify positive personality traits (A) may be beneficial in building self-esteem but is not as urgent as addressing physical needs. Confronting denial and defense mechanisms (C) may lead to resistance and hinder the therapeutic relationship. Educating the client about alcohol misuse (D) is important but should be done after addressing immediate physical needs.
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.
A nurse is assessing a client who has schizophrenia. The client says, "I hear voices telling me what to do." This is an example of which of the following?
- A. Delusional disorder
- B. Associative looseness
- C. Hallucination
- D. Anhedonia
Correct Answer: C
Rationale: Auditory hallucinations are common in schizophrenia, involving hearing voices that are not real.
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.
A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?
- A. Call for assistance to place the client in restraints.
- B. Escort the client to an unlocked seclusion room.
- C. Offer the client a PRN antianxiety medication.
- D. Speak to the client calmly, giving simple directions.
Correct Answer: D
Rationale: The correct answer is D: Speak to the client calmly, giving simple directions. This is the first action the nurse should take because it focuses on de-escalating the situation and ensuring the safety of the client and others. By speaking calmly and giving simple directions, the nurse can help the client regain control and potentially prevent further escalation. Calling for assistance to place the client in restraints (A) should only be used as a last resort for safety reasons. Escorting the client to an unlocked seclusion room (B) may escalate the situation further. Offering a PRN antianxiety medication (C) should only be considered after assessing the client and obtaining an order from a healthcare provider.