The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?
Encourage the client to be calm and relax for a little while.
Teach the client thought stopping techniques and ways to refocus behaviors.
Assist the client to identify stimuli that precipitates the activity.
Allow time for the behavior and then redirect the client to other
The Correct Answer is D
A. Simply encouraging the client to be calm and relax may not be effective for someone with obsessive-compulsive disorder.
B.
Teaching techniques is more appropriate for structured therapy sessions rather than addressing compulsive behavior in the moment.
C. While identifying stimuli can be useful, it is not an immediate intervention.
D.
This approach respects the client’s need to complete the compulsion to reduce anxiety while gradually redirecting attention, minimizing distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measuring abdominal girth is not specific to suprapubic catheter care. While it may be relevant in certain situations, it does not directly assess the condition of the catheter or its insertion site.
B. Assessing the perineal area is important, but the primary focus for a client with a suprapubic catheter should be on the insertion site itself, as this is where complications such as infection or leakage are most likely to occur.
C. Assessing the insertion site is essential to monitor for any signs of infection, inflammation, or other complications related to the catheter. This assessment helps ensure the catheter is functioning correctly and that no adverse effects are developing.
D. Palpating the flank area is generally not a routine assessment for a client with a suprapubic catheter unless there are specific concerns about kidney function or pain in that area.
Correct Answer is ["A","B","C","E"]
Explanation
A. It is important to add the egg allergy to the client's identification arm band to alert all healthcare providers of the allergy, ensuring the safety of the client by preventing accidental exposure.
B. Asking the client to describe her reactions can help the healthcare team understand the severity of the allergies and tailor care appropriately.
C. Entering the new allergy information into the client's electronic medical record is crucial for maintaining an up-to-date health record and ensuring that all team members are aware of the allergies.
D. Eliminating chicken from the client's menu is not necessary unless the client has specifically stated an allergy to chicken. Lactose intolerance and egg allergy do not automatically imply a chicken allergy.
E. Notifying the dietary department of the client's egg intolerance is essential to prevent the inclusion of eggs in the client's meals, which could lead to an allergic reaction.
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