A 35-year-old client with OCD spends several hours each day arranging and rearranging household items in a specific order. The client becomes extremely distressed if the items are not arranged correctly. Which nursing intervention is most appropriate?
Assist the client in developing a structured schedule for activities of daily living
Provide education about the irrationality of the behavior
Collaborate with the client to set realistic goals for behavior change
Encourage the client to resist the urge to rearrange items
The Correct Answer is C
A. A structured schedule may help with overall daily functioning, but it does not specifically address the compulsive behavior.
B. Educating the client about the irrationality of the behavior is unlikely to reduce the compulsions, as this is a hallmark of OCD, where the individual is often unable to control the urges despite understanding their irrationality.
C. Collaborating with the client to set realistic, gradual goals for changing the compulsive behavior is key in treating OCD. This approach allows the client to have input into their treatment plan and promotes realistic, achievable progress.
D. Encouraging the client to resist the urge to rearrange items without providing a structured approach may lead to increased anxiety and frustration. Gradual exposure and behavior modification are more effective.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Reality testing refers to the ability to distinguish between what is real and what is not. The client’s belief is a symptom of grandiosity, not a lack of reality testing.
B. Derealization refers to the sense that the external world is unreal or distorted, which is not the case here.
C. Grandiosity is an inflated sense of self-importance and unrealistic beliefs in one’s abilities, as demonstrated by the client’s statement about being able to fly and become a U.S. Senator.
D. Flight of ideas involves rapid, continuous speech with fragmented thoughts that jump from one topic to another. The client’s speech does not exhibit this pattern.
Correct Answer is B
Explanation
A. Documenting the size and location is important for medical records, but it is secondary to providing immediate care for the wounds.
B. The first action is to inspect the cuts for any debris to ensure proper wound care. Cleaning the wounds and assessing their severity is necessary to prevent infection.
C. Administering a tetanus antitoxin is not the first step unless the cuts show signs of contamination or the patient is at risk of tetanus.
D. Implementing a behavioral modification plan is important for addressing self-harm behaviors, but the immediate priority is to assess and treat the cuts to prevent infection.
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