A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:
interrupt the handwashing and insist the client come to meals with everyone else.
provide the client's meals later and after the other clients have eaten.
notify the client when it is 30 minutes before the meal so they can begin their handwashing.
allow the client to continue as is but provide them access to the kitchen.
The Correct Answer is D
a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.
Correct Answer is B
Explanation
a. Clinically significant distress in occupational functioning. While distress in occupational functioning may occur, it is not specific to dissociative fugue and is more broadly associated with various mental health disorders.
b. Sudden unexpected travel or confused wandering. This choice is correct because dissociative fugue is characterized by sudden, unexpected travel away from one's home or usual place of work, with an inability to recall some or all of one's past.
c. An inability to recall their parent's contact information. While memory loss is part of dissociative fugue, the focus is on broader, more significant amnesia than just inability to recall specific information like contact details.
d. Occasional periods of forgetfulness. This does not capture the severity or the specific nature of the amnesia involved in dissociative fugue.
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