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 C
Explanation
Choice A: Blood alcohol level of 0.09% (90 mmol/L) is not the most important finding for the nurse to report, as this is within the reference range and does not indicate alcohol intoxication or withdrawal, which can affect the client's mental status and mood stability. This is a distractor choice.
Choice B: Six hours of sleep in the past three days is not the most important finding for the nurse to report, as this is a common symptom of bipolar disorder during manic episodes and does not require immediate intervention by the health care provider. This is another distractor choice.
Choice C: Serum lithium level of 1.6 mEq/L (1.6 mmol/L) is the most important finding for the nurse to report, as this indicates lithium toxicity, which can cause neurological and renal impairment and potentially fatal complications such as seizures, coma, and cardiac dysrhythmias. Therefore, this is the correct choice.
Choice D: Weight loss of 10 pounds (4.5 kg) in past month is not the most important finding for the nurse to report, as this may be related to decreased appetite or increased activity during manic episodes and does not pose an immediate threat to the client's health or safety. This is another distractor choice.
Correct Answer is ["A","B"]
Explanation
Choice A: Avoid salt substitutes. This client needs additional education, as salt substitutes may contain potassium, which can increase the risk of hyperkalemia in clients with coronary artery disease. The nurse should teach the client to use herbs, spices, or lemon juice to flavor food instead of salt or salt substitutes.
Choice B: Consume canned vegetables. This client needs additional education, as canned vegetables may contain sodium, which can increase the blood pressure and worsen coronary artery disease. The nurse should teach the client to choose fresh or frozen vegetables instead of canned ones.
Choice C: Include oatmeal for breakfast. This client does not need additional education, as oatmeal is a good source of soluble fiber, which can lower cholesterol and reduce the risk of atherosclerosis. The nurse should praise the client for this healthy choice.
Choice D: Identify foods with saturated fats. This client does not need additional education, as identifying foods with saturated fats is an important step to avoid them. Saturated fats can raise cholesterol and increase the risk of coronary artery disease. The nurse should teach the client to limit saturated fats to less than 10% of total calories per day.
Choice E: Walk 30 minutes per day. This client does not need additional education, as walking 30 minutes per day is a recommended physical activity for clients with coronary artery disease. Physical activity can improve blood circulation, lower blood pressure, and reduce stress. The nurse should encourage the client to walk at a moderate pace and consult with the healthcare provider before starting any exercise program.
Choice F: Keep a food diary. This client does not need additional education, as keeping a food diary is a helpful tool to monitor dietary intake and identify areas for improvement. The nurse should teach the client to record the type, amount, and time of food consumed, as well as any symptoms or feelings associated with eating.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.