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 A
Explanation
Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood flow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.
The other options are not correct because:
- Macular edema is a condition that causes swelling and fluid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not affect the optic nerve or the peripheral vision.
- Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not affect the optic nerve or the intraocular pressure.
- Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, fluctuating, or darkened vision, but it does not affect the optic nerve or the intraocular pressure.
Correct Answer is D
Explanation
This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.
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