A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the nurse that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the nurse to provide?
Unless your sister has a medical education, ignore her comments.
I can hear that your sister's comments are overwhelming you.
Do you think it is possible that you might be a hypochondriac?
Besides your sister's comments, what in your life is troubling you?
The Correct Answer is D
Choice A rationale: Ignoring comments about the sister's lack of medical education may not address the client's feelings and concerns. It is essential to explore the client's emotions.
Choice B rationale: Acknowledging that the sister's comments are overwhelming is supportive but may not actively address the client's self-perception.
Choice C rationale: Asking if the client thinks she might be a hypochondriac could be interpreted as judgmental and may not promote an open discussion about the client's concerns.
Choice D rationale: Asking about what is troubling the client, besides her sister's comments, encourages the client to express her feelings and provides an opportunity for the nurse to understand the client's perspective and concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Hydrochlorothiazide is a diuretic and may contribute to electrolyte imbalances, but it is not the most concerning medication in this situation. Choice B rationale: Phenelzine is a monoamine oxidase inhibitor (MAOI), and the combination of an MAOI with certain foods or medications containing tyramine can lead
to a hypertensive crisis. The client's elevated blood pressure is of concern, and the nurse should notify the healthcare provider.
Choice C rationale: Losartan is an angiotensin II receptor blocker (ARB) used to treat hypertension. While it may contribute to blood pressure control, it is not the most concerning medication in this scenario.
Choice D rationale: Aspirin, at a dose of 81 milligrams, is often used for cardiovascular prophylaxis and is not the most concerning medication in this situation.
Correct Answer is B
Explanation
Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).
Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.
Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.
Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.
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