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.

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E","F"]

Explanation

Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.

Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.

Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.

Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.

Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.

Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.

A. Restrict visitors to family members only. B. Discuss the client's suicide plan. C. Limit time allowed to play video games. D. Encourage the client to discuss thoughts and feelings about wanting to die. E. Reinforce statements regarding a will to live and realistic plans for the future.

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

Explanation

Choice A rationale:
Restricting visitors to family members only may not necessarily be a beneficial intervention and could potentially isolate the client further, which may not be in their best interest.

Choice B rationale:
Discussing the client's suicide plan is essential to assess the level of risk and develop strategies to keep the client safe. It allows the healthcare team to understand the severity of the client's depressive symptoms and potential suicidal ideation.

Choice C rationale:
Limiting the time allowed to play video games may be a consideration in a broader plan of care, but it is not a primary intervention for addressing depression in adolescents. The focus should be on safety, communication, and building a therapeutic relationship.

Choice D rationale:
Encouraging the client to discuss thoughts and feelings about wanting to die is crucial for therapeutic communication and assessment. It provides an opportunity for the client to express their emotions and allows for intervention and support.

Choice E rationale:
Reinforcing statements regarding a will to live and realistic plans for the future is important for building hope and motivation in the client. It can be part of a positive, strengths-based approach to treatment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","D","E","F"]

Explanation

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

Explanation

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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?