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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.
Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.
Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.
Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"c"},"D":{"answers":"B"},"E":{"answers":"C"}}
Explanation
Numbness: Rape-trauma syndrome: Numbness can be a symptom of the acute phase of rape trauma syndrome, where individuals may experience emotional detachment or a sense of being emotionally overwhelmed.
- Poor decision making: Alcohol intoxication: Poor decision making is a common symptom of alcohol intoxication due to impaired judgment and cognitive function caused by alcohol consumption.
- Crying: occurs in both alcohol intoxication and rape-trauma syndrome. Crying is a common emotional response during the acute phase of rape-trauma syndrome as individuals may experience intense feelings of sadness, fear, or helplessness. Crying may also occur in individuals experiencing alcohol intoxication, especially if they become emotionally overwhelmed or as a result of disinhibition caused by alcohol consumption.
- Disbelief: Disbelief or denial is a typical reaction in the acute phase of rape-trauma syndrome as individuals may struggle to come to terms with the reality of the traumatic event.
- Irritability: Alcohol intoxication can lead to irritability because lowered inhibitions often trigger mood swings, aggression, or emotional lability, while in the acute phase of rape‑trauma syndrome survivors may also exhibit irritability as part of their emotional response, commonly expressed through anger, restlessness, or heightened anxiety; therefore, irritability is a behavior that can be observed in both conditions
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