A nurse is caring for an 11-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddler sitting quietly in the corner of the crib, sucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmental reactions?

Developing autonomy

Regression

Resentment toward the mother

An anxiety reaction

Answer and Explanation

The Correct Answer is B

Incorrect:

A. Developing autonomy:

Rationale: Developing autonomy typically involves a toddler's exploration of their environment and assertion of independence. While seeking comfort in familiar behaviors like thumb-sucking can be a part of autonomy development, the behavior described in the scenario is more indicative of regression, which involves returning to earlier, more infantile behaviors rather than progressing towards independence.

B. Regression:

Rationale: Regression refers to reverting to behaviors characteristic of an earlier stage of development. In this scenario, the toddler's behavior of sitting quietly in the corner of the crib and sucking her thumb, as well as turning away from the nurse, suggests a regression to earlier comforting behaviors that are typical of younger infants. This regression may be a response to the stress and anxiety of being hospitalized and separated from the mother, seeking comfort in familiar behaviors.

C. Resentment toward the mother:

Rationale: There is no evidence in the scenario to suggest resentment toward the mother. The toddler's behavior of seeking comfort in thumb-sucking and turning away from the nurse is more indicative of distress or regression in response to the hospitalization and separation from the mother rather than directed resentment toward her.

D. An anxiety reaction:

Rationale: The toddler's behavior of sitting quietly in the corner of the crib, sucking her thumb, and turning away from the nurse suggests a response to stress or anxiety rather than an anxiety reaction per se. While anxiety may be a component of the toddler's emotional state, the behavior aligns more closely with regression as a coping mechanism in response to the stressors of hospitalization and separation from the mother.

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Correct Answer is A

Explanation

A. Plan the client's schedule to allow time for rituals: This is the most appropriate action. It is essential to recognize that compulsive behaviors in OCD serve as coping mechanisms for the individual. Allowing time for rituals within the client's schedule can help reduce anxiety and provide a sense of control. Gradual exposure and response prevention techniques can be incorporated into the treatment plan over time to help the client gradually decrease reliance on rituals.

B. Isolate the client for a period of time: Isolating the client may exacerbate feelings of anxiety and distress, as well as decrease opportunities for social interaction and support, which are essential components of mental health treatment.

C. Confront the client about the senseless nature of the repetitive behaviors: Confrontation may lead to defensiveness and resistance from the client. It is important to approach the client with empathy and understanding rather than judgment. Educating the client about the nature of OCD and the role of compulsive behaviors in managing anxiety can be more helpful in fostering insight and motivation for change.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules: Setting strict limits may increase the client's distress and resistance. It is important to collaborate with the client in treatment planning and find a balance between supporting the client's needs and maintaining a therapeutic environment. Gradual exposure and response prevention techniques should be implemented in a supportive manner rather than through strict enforcement.

A. "You are being unreasonable, and I will not call your doctor at this hour." B. "I can't call a doctor in the middle of the night unless it's an emergency C. "You must be very upset about something." D. "Go back to your room, and I'll try to get in touch with your doctor"

Correct Answer is C

Explanation

A. "You are being unreasonable, and I will not call your doctor at this hour."

This response may escalate the situation by invalidating the client's feelings and refusing to address their request. It fails to recognize the client's distress and could lead to increased agitation or frustration.

B. "I can't call a doctor in the middle of the night unless it's an emergency."

While it's true that non-urgent matters may be deferred until regular hours, this response comes across as dismissive and may exacerbate the client's distress. It does not validate the client's feelings or offer support.

C. "You must be very upset about something."

This response acknowledges the client's emotions and shows empathy. It opens the door for the client to express their concerns, allowing the nurse to assess the situation further and address any immediate needs. It also avoids dismissing the client's request outright and maintains a therapeutic relationship.

D. "Go back to your room, and I'll try to get in touch with your doctor."

This response instructs the client to return to their room without addressing their emotional state or concerns. It lacks empathy and fails to engage with the client's needs effectively.

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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 nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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