A client with obsessive-compulsive disorder (OCD. 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 while.
Teach the client thought-stopping techniques and how to refocus behaviors.
Assist the client to identify stimuli that precipitate the activity.
Allow time for the behavior and then redirect the client to other activities.
The Correct Answer is D
Choice D is correct because allowing time for the behavior and then redirecting the client to other activities is an effective intervention for a client with OCD who is repeatedly washing the top of the same table. OCD is a disorder characterized by recurrent and intrusive thoughts (obsessions) and repetitive and ritualistic behaviors (compulsions) that cause distress and impairment. The nurse should not interfere with or criticize the client's compulsions, as this can increase anxiety and resistance. The nurse should instead set limits on the time and place for the compulsions and gradually reduce them by offering alternative coping strategies or distractions.
Choice A is incorrect because encouraging the client to be calm and relax for a while is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. The client may not be able to relax or stop their compulsions, as they are driven by irrational fears or beliefs that are difficult to control. The nurse should not minimize or dismiss the client's feelings, as this can make them feel misunderstood or invalidated.
Choice B is incorrect because teaching the client thought-stopping techniques and how to refocus behaviors is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. Thought-stopping techniques are cognitive strategies that aim to interrupt or replace negative or unwanted thoughts with positive or neutral ones. However, these techniques may not work for clients with OCD, as their obsessions are often persistent and resistant to change. The nurse should not attempt to teach new skills or challenge the client's thoughts during an acute episode of compulsion, as this can increase anxiety and frustration.
Choice C is incorrect because assisting the client to identify stimuli that precipitate the activity is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. The client may not be able to identify or avoid the triggers that cause their compulsions, as they are often internal or irrational. The nurse should not focus on finding the cause or meaning of the compulsions, as this can reinforce their significance or validity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Providing diet low in phosphorus is not a relevant intervention for a client with cirrhosis of the liver. Phosphorus is a mineral that helps maintain bone health and acid-base balance. Cirrhosis of the liver does not affect phosphorus levels, but it can cause low calcium levels due to impaired vitamin D metabolism. The nurse should provide a diet high in calcium and vitamin D to prevent osteoporosis and fractures.
Choice C reason: Increasing oral fluid intake to 1,500 mL daily is not a suitable intervention for a client with cirrhosis of the liver. Fluid intake should be individualized based on the client's fluid status, electrolyte levels, and urine output. Increasing fluid intake may worsen fluid retention and electrolyte imbalance in clients with cirrhosis of the liver. The nurse should restrict fluid intake to 1,000 to 1,500 mL daily or as prescribed by the healthcare provider.
Correct Answer is B
Explanation
Choice A reason: Support stockings may help with peripheral edema, but they are not the priority intervention for this client. The client's low serum albumin level indicates malnutrition and increased risk of infection and poor wound healing.
Choice C reason: Evaluating patency of the AV graft is not the priority intervention for this client because the client is receiving peritoneal dialysis, not hemodialysis. The AV graft may be used in the future if peritoneal dialysis fails, but it is not an immediate concern.
Choice D reason: Instructing the client to follow fluid restriction amounts is important for peritoneal dialysis patients, but it is not the priority intervention for this client. The client's low serum albumin level indicates that fluid restriction alone is not sufficient to manage fluid balance and prevent edema.
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