A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Discuss the problem in a community meeting with the other clients on the unit present.

Escort the client to her room each time the nurse observes the client socializing with other clients.

Talk to the client and identify the specific limits that are required of the client's behavior.

Tell the other clients to ignore the client's lies

Answer and Explanation

The Correct Answer is C

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.

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Correct Answer is A

Explanation

A. Plan the client's schedule to allow time for rituals.

Explanation:

For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.

Why the other choices are incorrect:

B. Confront the client about the senseless nature of the repetitive behaviors.

Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.

C. Isolate the client for a period of time.

Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.

A. Change policies for staff observation of clients who are suicidal. B. Identify cues in the client's behavior that might have warned them that he was contemplating suicide. C. Provide professional counseling for staff members. D. Give the family an opportunity to talk about their feelings.

Correct Answer is B

No explanation

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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

Correct Answer is A

Explanation

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?

Correct Answer is B

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