A client with obsessive-compulsive disorder (OCD) reports, "Thoughts stick in my mind and the rituals I use are stupid, but I cannot control them. People laugh at me, but they do not understand how awful it is. I am a burden to my family because I cannot hold a job. I do not know how much longer I can live this way." Which information is most important for the practical nurse (PN) to ask in response to the client's statements?
Question about which rituals are most often used to reduce anxiety.
Ask if the obsessions and compulsions interfere with sleep.
Inquire if the distress could lead to considering suicide as an option.
Determine what makes the client think people are laughing.
The Correct Answer is C
This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.
A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.
B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.
D. Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is: Choice C - Check the pedal pulse in the affected leg.
Rationale:
- Choice A: Massage the calf and foot: While massage can be helpful for relieving muscle cramps in some cases, it is not the most appropriate first step in this situation. A leg cramp during labor could be a sign of a more serious condition, such as a blood clot (deep vein thrombosis or DVT). Massaging the area could potentially dislodge the clot and cause a pulmonary embolism (PE), a life-threatening condition.
- Choice B: Extend the leg and flex the foot: This maneuver may stretch the calf muscle and temporarily relieve the cramp, but it doesn't address the underlying cause. Additionally, extending the leg completely could be uncomfortable for the woman in labor.
- Choice C: Check the pedal pulse in the affected leg: This is the most crucial step. A weak or absent pedal pulse in the affected leg could be a strong indicator of DVT. Checking the pulse allows the nurse to assess for potential complications and escalate care if necessary.
- Choice D: Elevate the leg above the heart: Elevation can be helpful for reducing swelling and improving circulation, but it's not the primary concern in this case. Checking the pulse takes priority to assess for circulatory compromise.
Summary:
Leg cramps during labor can be caused by various factors, but it's essential to rule out more serious conditions like DVT. Checking the pedal pulse is the initial step to assess circulation and identify potential complications. If the pulse is weak or absent, the nurse should notify the healthcare provider immediately for further evaluation and treatment.
Correct Answer is C
Explanation
"I realize that my life must go on, but sometimes I wonder why.”
Choice A rationale:
This statement may indicate frustration with physical limitations, which is common in older adults, especially after surgery. It does not necessarily indicate a need for bereavement counseling.
Choice B rationale:
Difficulty remembering simple things can be attributed to normal aging processes or other factors not directly related to bereavement.
Choice C rationale:
Expressing a sense of wondering "why”. after the loss of a spouse suggests ongoing grief and a potential need for bereavement counseling to process feelings and find meaning in life after the loss.
Choice D rationale:
Depending on children who live close-by is a common support mechanism for older adults and does not directly indicate a need for bereavement counseling.
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