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. After straight catheterization, assessing for residual urine volume in the bladder helps determine if the bladder has emptied adequately. Palpation of the client's bladder can provide information about residual urine volume.
B. Replacing the catheter with an indwelling catheter is not indicated unless there are specific reasons for continuous drainage.
C. Allowing the bladder to empty further without assessing for residual distention may lead to incomplete bladder emptying, which can cause urinary retention and discomfort.
D. Clamping the catheter for thirty minutes is not appropriate after straight catheterization and may result in urinary retention or discomfort for the client.
Correct Answer is ["B","C","D","E"]
Explanation
A. Advising the nurse to use the plunger when giving medications is not recommended as it can create too much pressure and potentially damage the gastrostomy tube or cause discomfort to the patient. It's important to allow the medication to flow by gravity to prevent these issues.
B. Encouraging the nurse to flush the tube with more water is correct because it helps to ensure that the medication is cleared from the tube and reduces the risk of clogging. Flushing with water also helps to maintain hydration for the patient.
C. Confirming that the nurse determined the amount of gastric residual is correct because it is essential to check for any undigested food or medication in the stomach before administering more. This helps to prevent aspiration and other complications.
D. Instructing the nurse to administer each medication separately is correct. This practice
prevents drug interactions within the tube and ensures that each medication is given correctly and has the intended effect.
E. Adding the liquid volumes when documenting fluid intake is correct because all fluids
administered, including medications, should be accounted for in the patient's fluid balance. This is crucial for monitoring and managing the patient's hydration status and overall health.
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