The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.

Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.

Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.

Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.

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Correct Answer is D

Explanation

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.

A. Concentrate on and ventilate emotions when distressed. B. Shift attention from self to the needs and requests of others. C. Relax and reduce the amount of effort to solve the problem. D. Focus on small achievable tasks, not taxing problems.

Correct Answer is D

Explanation

Choice A Rationale:
While emotional expression and ventilation can be therapeutic, it may not be the most appropriate coping strategy for someone with depression who may already be overwhelmed by negative emotions. Ventilating emotions without a structured approach might not provide the desired relief and can even exacerbate feelings of distress.

Choice B Rationale:
This choice may not be suitable for someone with depression because it could lead to further neglect of their own needs and contribute to feelings of guilt or exhaustion.

Choice C Rationale:
While relaxation techniques can be helpful, reducing the effort to solve problems may not be the most effective strategy for individuals with depression. Avoidance of problems can perpetuate feelings of helplessness and hopelessness.

Choice D Rationale:
For a client with depression who is struggling with handling personal circumstances, focusing on small achievable tasks can be a helpful coping strategy. Breaking down larger problems into manageable steps can reduce feelings of overwhelm and gradually improve the client's sense of accomplishment and self-efficacy.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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