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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?

A.

Question about which rituals are most often used to reduce anxiety.

B.

Ask if the obsessions and compulsions interfere with sleep.

C.

Inquire if the distress could lead to considering suicide as an option.

D.

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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Related Questions

Correct Answer is A

Explanation

The correct answer is Choice A:

Assist in turning the client to one side. Choice A rationale:

When preparing a client with obstructive sleep apnea for sleep, the practical nurse (PN) should assist the client in turning to one side. This position is known as the lateral position and can be beneficial for clients with obstructive sleep apnea. Lying on one's side can help to reduce the likelihood of airway obstruction and minimize the occurrence of apnea (pauses in breathing) during sleep. This position promotes better airflow and can improve the client's overall sleep quality.

Choice B rationale:

Keeping oral suction equipment nearby (Choice B) might be appropriate for clients with respiratory issues or a risk of airway obstruction. However, it is not the best action for a client with obstructive sleep apnea. Sleep apnea primarily involves upper airway collapse, not excessive secretions or obstructions in the oral cavity.

Choice C rationale:

Offering to bring the client a sleeping pill (Choice C) is not an appropriate action for a client with obstructive sleep apnea. Sleep apnea is characterized by repeated episodes of blocked or restricted airflow during sleep. Sedative medications can further relax the muscles in the airway, worsening the condition and potentially leading to more severe apnea.

Choice D rationale:

Placing a cool air humidifier in the room (Choice D) may be helpful for clients who experience dryness or congestion in the airways during sleep. However, it is not specifically indicated for obstructive sleep apnea. While humidifiers can be beneficial for some sleep-related issues, they do not address the underlying cause of sleep apnea.

Correct Answer is ["A","C","D"]

Explanation

The correct answer is choice A, C, and D. Choice A rationale: Boiled brown rice is a good option for a client with renal disease needing to limit salt intake. It is low in sodium and does not contribute to fluid retention. Choice B rationale: Canned tomato soup is typically high in sodium, which can lead to fluid retention and increased blood pressure, making it an unsuitable choice for someone with renal disease who needs to limit salt intake. Choice C rationale: Fresh orange slices are low in sodium and high in vitamin C. They do not contribute to fluid retention and are suitable for a client with renal disease on a low-salt diet. Choice D rationale: Grilled chicken, especially if not seasoned with salt, is a low-sodium protein source that fits within the dietary restrictions for a client with renal disease. Choice E rationale: Vegetables are generally a good choice, but topping them with cheddar cheese increases the sodium content significantly, making it an inappropriate choice for someone on a low-salt diet, as cheese is often high in sodium.

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