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
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.
Correct Answer is ["A","E"]
Explanation
Choice A: Consuming foods with saturated fats is not a healthy lifestyle change for a client with coronary artery disease, as this can increase the level of cholesterol and triglycerides in the blood, which can lead to plaque formation and narrowing of the arteries. Therefore, this statement indicates that the client needs additional education.
Choice B: Walking 30 minutes per day is a beneficial lifestyle change for a client with coronary artery disease, as this can improve the blood circulation, lower the blood pressure, and reduce the risk of heart attack and stroke. Therefore, this statement does not indicate that the client needs additional education.
Choice C: Using a salt substitute is a helpful lifestyle change for a client with coronary artery disease, as this can reduce the sodium intake, which can lower the blood pressure and prevent fluid retention. Therefore, this statement does not indicate that the client needs additional education.
Choice D: Keeping a food diary is a useful lifestyle change for a client with coronary artery disease, as this can help the client monitor their calorie intake, portion size, and nutritional quality of their food. This can also help the client identify and avoid unhealthy food choices. Therefore, this statement does not indicate that the client needs additional education.
Choice E: Eating more canned vegetables is not a good lifestyle change for a client with coronary artery disease, as canned vegetables often contain high amounts of sodium, which can raise the blood pressure and worsen the condition. Therefore, this statement indicates that the client needs additional education.
Choice F: Including oatmeal for breakfast is an advantageous lifestyle change for a client with coronary artery disease, as oatmeal contains soluble fiber, which can lower the cholesterol level and prevent plaque formation in the arteries. Therefore, this statement does not indicate that the client needs additional education.
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