A mental health nurse is caring for a newly admitted client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
Instruct the client on relaxation techniques for use when anxiety level increases.
Discuss many alternative coping strategies with the client.
Identify precipitating factors for ritualistic behaviors.
Provide a highly structured activity schedule for the client.
The Correct Answer is C
Choice A rationale: Instructing the client on relaxation techniques for use when anxiety level increases is a beneficial intervention for a client with OCD. However, it is not the first action the nurse should take. The nurse needs to understand the client’s condition, including the triggers for their ritualistic behaviors, before they can effectively guide the client in managing their anxiety.
Choice B rationale: Discussing many alternative coping strategies with the client is an important part of OCD management. However, this should come after understanding the client’s condition and the triggers for their ritualistic behaviors. Without this understanding, the coping strategies suggested may not be effective or relevant.
Choice C rationale: Identifying precipitating factors for ritualistic behaviors is the first action the nurse should take. Understanding what triggers the client’s OCD behaviors is crucial in developing an effective care plan. This understanding allows the nurse to work with the client to develop strategies to manage their triggers and reduce the frequency and intensity of their OCD behaviors.
Choice D rationale: Providing a highly structured activity schedule for the client can be helpful in managing OCD. However, this should not be the first action. The nurse needs to first understand the client’s condition, including the triggers for their ritualistic behaviors. This understanding will allow the nurse to develop a schedule that takes into account the client’s triggers and incorporates effective coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Providing privacy when friends visit is a general good practice in nursing. However, it may not be the most effective intervention for a client with anorexia nervosa. Anorexia nervosa is characterized by a distorted body image and an intense fear of gaining weight. While privacy is important, it is not directly related to the management of anorexia nervosa.
Choice B rationale: Scheduling regular weigh-in times is a key intervention for clients with anorexia nervosa. Regular weigh-ins help monitor the client’s progress and any potential complications related to weight loss. This intervention is directly related to the management of anorexia nervosa and is therefore the correct answer.
Choice C rationale: Complimenting the client for weight gain can be a sensitive issue for individuals with anorexia nervosa. While it might seem like a positive reinforcement, it could potentially trigger anxiety and fear in the client, as individuals with anorexia nervosa have an intense fear of gaining weight. Therefore, this intervention should be handled with care and is not the best choice in this scenario.
Choice D rationale: Allowing the client to eat at any time might seem like a good idea, but it is not the most effective intervention for a client with anorexia nervosa. Individuals with anorexia nervosa often have strict rituals and rules around eating. Allowing them to eat at any time might not address these underlying issues and could potentially enable their disordered eating habits.
Correct Answer is D
Explanation
Choice A rationale:
Seclusion may be considered for a school-age client who repeatedly bites staff as a method of last resort to ensure the safety of both the client and staff.
It's important to exhaust other interventions first, such as verbal de-escalation, redirection, and medication.
If seclusion is used, it should be implemented under strict guidelines, with close monitoring and frequent reassessment to determine its effectiveness and necessity.
Choice B rationale:
Seclusion may be considered for an older adult client who is manic and agitated due to overstimulation, as it can provide a safe and quiet environment to reduce sensory input and promote calming.
However, it's crucial to carefully assess the client's physical and cognitive status, as seclusion can exacerbate confusion and disorientation in older adults.
Close monitoring and reassessment are essential.
Choice C rationale:
Seclusion may be considered for an adolescent client who throws objects at other clients to maintain safety and prevent harm to others.
It's important to first attempt other interventions, such as verbal de-escalation, redirection, and limit-setting.
If seclusion is used, it should be brief and implemented with therapeutic goals in mind, such as promoting self-regulation and problem-solving skills.
Choice D rationale:
Seclusion is contraindicated for an adult client after an interrupted suicide attempt.
This is because seclusion can increase isolation, hopelessness, and despair, which are significant risk factors for suicide.
It can also hinder close observation and monitoring of the client's mental state, potentially leading to further suicide attempts.
Instead, the focus should be on providing supportive, one-to-one contact, ensuring safety, and establishing therapeutic rapport to address the underlying issues that led to the suicide attempt.
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