A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Determine the type and size of the locks.

Plan a list of activities to be carried out daily.

Discuss checking the time frequently.

Ask the client why the locks are checked so frequently.

Answer and Explanation

The Correct Answer is B

- Choice A Rationale: Determining the type and size of the locks does not address the client's anxiety or the behavior that is impacting their daily functioning. This action might inadvertently reinforce the client's focus on the locks rather than addressing the underlying issue.
- Choice B Rationale: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on the day's tasks and can provide a sense of control and accomplishment.
- Choice C Rationale: Discussing checking the time frequently does not directly address the client's repetitive behavior or the associated anxiety. While time management may be part of a broader treatment plan, it is not the most immediate action the nurse should take.
- Choice D Rationale: Ask the client why the locks are checked so frequently is not therapeutic and may put the client on the defensive. Clients with obsessive-compulsive behaviors often cannot explain why they perform rituals, as the behavior is driven by anxiety rather than logic. Asking "why" may increase frustration without helping to address the behavior.

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Correct Answer is ["B","C","D"]

Explanation

A. Restricting visitors may exacerbate feelings of isolation and may not be therapeutic for the adolescent client who is depressed.
B. Reinforcing statements regarding a will to live and realistic plans for the future can provide hope and motivation for the adolescent to engage in treatment and recovery.
C. Understanding the client's suicide plan is crucial for assessing risk and planning appropriate interventions to ensure safety.
D. Encouraging the client to discuss thoughts and feelings promotes open communication and allows the adolescent to express emotions, which can be therapeutic and supportive in managing depression.
E. While limiting excessive screen time, including video games, may be beneficial for overall well-being, it may not directly address the underlying issues contributing to the adolescent's depression and may be less relevant in the immediate plan of care.

A. Ignore the nonverbal behavior and focus on the client's verbal messages. B. Integrate the verbal and nonverbal messages and interpret them as one. C. Ask the client's spouse to interpret the discrepancy. D. Pay close attention and document the nonverbal messages.

Correct Answer is D

Explanation

A. Ignoring nonverbal behavior may overlook important cues that could provide valuable insight into the client's condition and needs.
B. Integrating verbal and nonverbal messages is important, but it may not address the discrepancy or the potential significance of the nonverbal cues.
C. Asking the client's spouse to interpret the discrepancy may not be appropriate or effective, as the spouse may not fully understand the client's nonverbal cues or their significance.
D. Paying close attention and documenting nonverbal messages allows the nurse to gather comprehensive data and potentially explore the observed discrepancy further in subsequent interactions or assessments.

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A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

Correct Answer is D

Explanation

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