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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Rationale for A: Elevated energy level is a common effect of cocaine use, but it does not encompass the full range of behaviors associated with the drug's effects.
Rationale for B: Powerful cravings for more cocaine can develop over time, especially after the initial effects wear off, but they are not the immediate behavior observed.
Rationale for C: High self-esteem may be a temporary effect, but it does not specifically indicate current behavior associated with cocaine use.
Rationale for D: Euphoria is one of the primary effects of cocaine and is typically experienced shortly after use. This intense feeling of pleasure is a hallmark behavior observed in clients who have recently used cocaine.
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