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 B
Explanation
This is the best intervention for the PN to implement because it relieves the muscle spasm and reduces the pain of a leg cramp. Leg cramps are common during pregnancy and labor due to changes in calcium levels, fluid balance, or pressure on nerves and blood vessels.
A. Massaging the calf and foot is not recommended because it may increase pain or cause injury to the muscle or nerve.
C. Checking the pedal pulse in the affected leg is not necessary unless there is a suspicion of vascular compromise or thrombosis, which are unlikely causes of a leg cramp.
D. Elevating the leg above the heart is not helpful because it may impair blood flow or increase pressure on the nerve or muscle.
Correct Answer is B
Explanation
This is the observation that indicates that the UAPs need additional information about the turning procedure because it is incorrect and may cause complications for the client. The client who had a hip arthroplasty with prosthesis placement should not keep both legs straight and together while turning because this may cause dislocation of the prosthesis, nerve damage, or bleeding. The client should keep the affected leg slightly abducted and supported with pillows or an abduction device.
A. An abduction pillow is placed between the client's legs when positioned correctly and does not indicate a need for additional information. This helps to maintain proper alignment and prevent dislocation of the prosthesis.
C. A turning sheet is used under the client for turning and repositioning is correct and does not indicate a need for additional information. This helps to reduce friction and shear forces on the skin and prevent pressure ulcers.
D. The UAPs keep their backs straight and knees bent when moving the client is correct and does not indicate a need for additional information. This helps to protect their own musculoskeletal health and prevent injuries.
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