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 C

Explanation

Choice A rationale:

Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.

Choice B rationale:

Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.

Choice C rationale:

Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.

Choice D rationale:

Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.

A. Observe the progression of the seizure. B. Loosen clothing around the neck. C. Insert a tongue blade between the teeth. D. Hold the extremities close to the body. E. Pad the side rails with pillows.

Correct Answer is ["A","B","E"]

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

Correct Answer is C

Explanation

The practical nurse (PN) is caring for a child who was admitted after experiencing a generalized tonic-clonic seizure. When witnessing the child begin to seize again, which actions should the PN implement immediately? (Select all that apply.).

Correct Answer is ["A","B","E"]

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge of the unit take?

A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

A client is admitted for treatment of Addison's crisis. Which finding is most important for the practical nurse (PN) to report to the charge nurse? Reference Range: Glucose [Reference Range: 0 to 50 years: less than 140 mg/dL or less than 7.8 mmol/L].

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

Which task could the practical nurse (PN) safely delegate to the unlicensed assistivepersonnel (UAP)?

An adult female client with type 1 diabetes mellitus is receiving NPH insulin 35 units each morning. Which finding should the practical nurse (PN) document as evidence that the amount of insulin is inadequate? (Reference Range: Glucose [0 to 50 years: less than 140 mg/dL or less than 7.8 mmo/L]).

An older female adult who was admitted to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

The practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?