A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?
Ask the client why she checks the locks.
Determine the type and size of the locks.
Discuss checking the time frequently.
Plan a list of activities to be carried out daily.
The Correct Answer is D
- A: Asking the client why she checks the locks may provide insight into her anxieties but does not directly address the behavior or its impact on her daily functioning.
- B: Determining the type and size of the locks does not address the client's behavior or the underlying anxiety causing the behavior.
- C: Discussing checking the time frequently could help with time management but does not address the compulsive behavior or its root cause.
- D: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on tasks and manage time more effectively, potentially reducing the impact of her compulsive behaviors on daily functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.
Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.
Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.
Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.
Correct Answer is ["A","C","D","F"]
Explanation
Choice A rationale:
This reflects a potential misunderstanding about the diagnosis and may contribute to stigma. The nurse should provide education and clarify that having acute stress disorder or similar responses to trauma does not mean the client is "crazy."
Choice B rationale:
This statement reflects a positive attitude toward therapy and self-improvement. There is no immediate need for follow-up teaching in this statement, as it aligns with the potential benefits of therapy for coping with trauma.
Choice C rationale:
This indicates the client's interest in holistic approaches, which is positive. However, the nurse should provide information and guidance on the use of such approaches in conjunction with other treatments.
Choice D rationale:
This suggests that the client may believe her response is typical. The nurse should provide education about the variability in individual responses to stress and trauma.
Choice E rationale:
This statement shows an understanding of the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While it's true that having ASD can increase the risk of developing PTSD, this statement does not require immediate follow-up teaching. However, the client should receive ongoing education about managing and preventing PTSD
Choice F rationale:
This raises concerns about the client's expectations regarding the duration of medication. The nurse should provide information about the intended duration of medication and the importance of ongoing assessment and follow-up with healthcare providers.
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