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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and oﬀers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.

B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.

C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

A. Insert an indwelling catheter to empty the bladder and contract the fundus. B. Return the client to bed and maintain bedrest until the lochial flow slows. C. Check fundal consistency and continue to monitor the lochial flow amount. D. Massage the fundus and avoid direct pressure on the cesarean incision.

Correct Answer is C

Explanation

Check fundal consistency and continue to monitor the lochial flow amount.

Choice A rationale:

Inserting an indwelling catheter to empty the bladder and contract the fundus is not the appropriate action for a sudden gush of vaginal blood and blood clots. The priority here is to assess the fundus, not intervene with an indwelling catheter. Catheterization may be necessary for other reasons, but not in this context.

Choice B rationale:

Returning the client to bed and maintaining bedrest until the lochial flow slows may be a reasonable initial response, but it is not the most appropriate action. The sudden gush of blood and presence of blood clots could be indicative of postpartum hemorrhage or retained placental tissue, which require prompt evaluation.

Choice C rationale:

Checking fundal consistency and continuing to monitor the lochial flow amount is the most appropriate action. The sudden gush of blood and clots suggest a possible uterine atony or retained products of conception. Assessing the fundal height and firmness helps identify if the uterus is contracting adequately, while monitoring the lochial flow amount can indicate ongoing bleeding.

Choice D rationale:

Massaging the fundus and avoiding direct pressure on the cesarean incision is not the recommended action in this situation. Massaging the fundus without assessing its consistency could worsen bleeding if there is uterine atony, and the client needs immediate evaluation and monitoring.

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Naxlex Comprehensive Predictor Exams

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

Correct Answer is D

Explanation

On the first day after a cesarean section, a client who is a primipara is being assisted to the bathroom for the first time. The client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. Which action should the practical nurse (PN) take?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a client with fractured metatarsals after slamming a hand in the car door. After administering the prescribed hydrocodone/acetaminophen for pain, which intervention should the PN include in the client's care?

The practical nurse (PN) receives shift report for four newborns in the full-term newborn nursery. Which infant should the PN assess first?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the practical nurse (PN) to include in the assessment of this client?

A 16-year-old client is asking the practical nurse (PN) what can be done about acne. Which recommendation should the PN provide?

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?