A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:

interrupt the handwashing and insist the client come to meals with everyone else.

provide the client's meals later and after the other clients have eaten.

notify the client when it is 30 minutes before the meal so they can begin their handwashing.

allow the client to continue as is but provide them access to the kitchen.

Answer and Explanation

The Correct Answer is D

a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.

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Correct Answer is B

Explanation

a. "I may consider dating you once you have fully recovered." This response, while seemingly kind, is unprofessional. It creates a false sense of hope for the client and blurs the professional line.
b. "This is a professional relationship, and we need to be clear on that." This is a direct and professional way to set boundaries. It reminds the client of the nature of the relationship and avoids any misunderstanding.
c. "It's against hospital policy for me to date clients." While some hospitals might have such policies, this isn't always the case. A broader and more direct response like option b is preferable.
d. "I'm sorry, but I'm married and not interested in dating." This response might be true, but it focuses on the nurse's personal life and deflects from the professional aspect. Option b is more appropriate.

A. leave the client alone to work out the problem, then tell the physician about the incident. B. tell the client to return to room and write their thoughts in a journal. C. give the prescribed flumazenil 5 mg IM D. remain with the client and ensure safety.

Correct Answer is D

Explanation

a. Leave the client alone: Leaving the client alone during a flashback could be dangerous.
b. Journaling: While journaling can be helpful for managing PTSD, it's not appropriate during a crisis situation.
c. Flumazenil: Flumazenil is used to reverse benzodiazepine overdose, not for PTSD flashbacks.
d. remain with the client and ensure safety: A PTSD flashback can be overwhelming and lead to self-harm or aggression. The nurse's priority is to ensure the client's safety and the safety of others.

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A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:

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Naxlex Comprehensive Predictor Exams

After having one conversation with a female nurse, a young male client asks the nurse for her phone number. He says that he would like to date her. Which of the following responses would be most appropriate?

Correct Answer is B

Explanation

A client, who was diagnosed with Post Traumatic Stress Disorder (PTSD), is now experiencing flashbacks and is displaying irritable behavior. The nurse would:

Correct Answer is D

Explanation

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