A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

"Have you had a bad experience related to unlocked doors?"

"What are your thoughts when you are checking the locks?"

"Repeating the same behavior helps you to diminish your anxiety."

"Feelings of being driven to do something are related to anxiety."

Answer and Explanation

The Correct Answer is B

Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).

Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.

Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.

Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.

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Correct Answer is B

Explanation

A. The client will eat nutritious meals in the hospital cafeteria.
While eating nutritious meals is essential for the physical recovery of the adolescent, improving self-esteem is the highest priority in the treatment of anorexia nervosa. A negative body image and poor self-esteem are central to the disorder, and addressing these underlying psychological factors can foster more effective long-term recovery. Although ensuring the client eats is important, achieving a positive self-image is fundamental for encouraging healthier eating behaviors and overall recovery.

B. The client will verbalize feelings of a positive self-esteem.
This goal is the most appropriate because it targets the core psychological issues that contribute to anorexia nervosa, such as distorted body image and low self-worth. Enhancing the client’s self-esteem can improve their willingness to engage in healthier behaviors, including eating, which directly supports both the physical and emotional aspects of recovery. Verbalizing positive self-esteem is a key step in addressing the psychological distortions that drive the disorder.

C. The family will communicate their love and concern to the client.
While family support is vital to the recovery process, the priority should be on the adolescent’s internal psychological healing. Family communication is important for creating a supportive environment, but it is secondary to addressing the client’s self-esteem and the immediate needs of recovery from anorexia nervosa.

D. The entire family will attend family therapy sessions regularly.
Family therapy is important, but it is not the highest priority in the acute phase of treatment. In the beginning stages of treatment, the focus should be on addressing the adolescent’s psychological and nutritional needs. Family therapy can be integrated later in the treatment plan once the client’s basic physical and emotional health are stabilized.

A. It is essential not to abruptly discontinue taking the medication. B. I should report any dizziness, lightheadedness, or sedation. C. Attending individual and group therapy sessions is important. D. I can report any decrease in anxiety using the 10 point scale.

Correct Answer is A

Explanation

Choice A rationale: Abrupt discontinuation of alprazolam, a benzodiazepine used to treat anxiety disorders, can lead to withdrawal symptoms, including rebound anxiety,

insomnia, and potentially seizures. The statement reflects an understanding of the importance of gradual tapering and not abruptly stopping the medication. Choice B rationale: Reporting side effects such as dizziness, lightheadedness, or sedation is important, but the key focus for long-term benzodiazepine use is the need to avoid abrupt discontinuation.

Choice C rationale: While attending therapy sessions is beneficial for managing anxiety, the question is specifically addressing the self-care goal related to medication use. Choice D rationale: Reporting any decrease in anxiety using a 10-point scale is relevant but not as crucial as emphasizing the avoidance of abrupt discontinuation.

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A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

Correct Answer is B

Explanation

The nurse is preparing a client for discharge who has been taking alprazolam long-term for generalized anxiety disorder (GAD). When evaluating the client's grasp of the discharge teaching, which statement made by the client shows an understanding of the most important self-care goal?

Correct Answer is A

Explanation

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