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. "Ask the client why she checks the locks."
Asking "why" questions may put the client on the defensive and does not effectively address the compulsive behavior. Clients with obsessive-compulsive disorder (OCD) often do not have a logical explanation for their compulsions.
B. "Determine the type and size of the locks."
This action does not address the client’s compulsive behavior and is not relevant to the nursing intervention. The focus should be on reducing the compulsive behavior rather than assessing the locks themselves.
C. "Discuss checking the time frequently."
This response does not directly address the client’s compulsive checking behavior. Instead, structured interventions that promote time management and coping strategies should be implemented.
D. "Plan a list of activities to be carried out daily."
Providing a structured daily schedule can help redirect the client’s focus away from compulsive behaviors and toward productive activities. A schedule can reduce anxiety and limit the time available for compulsions, promoting better functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.
Correct Answer is B
Explanation
A. Assisting the client with relaxation techniques within the group may be ineffective for severe anxiety because the client may be too overwhelmed by the environment to participate or focus.
B. Escorting the client from the group to a quieter environment is the most effective intervention for severe anxiety. Reducing external stimuli allows the client to regain composure and prevents escalation of physiological and psychological stress responses.
C. Providing education about coping strategies is appropriate for mild or moderate anxiety, but during severe anxiety the client is unlikely to process or retain information effectively.
D. Asking the client to describe or identify the source of feelings can increase anxiety and is not therapeutic during a severe anxiety episode. Exploration of triggers is more appropriate once the client is calmer.
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