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
The correct answer is choice b. Moderate.
Choice A rationale: Severe anxiety is characterized by a significant reduction in the ability to perceive and process information. The individual may experience intense physical symptoms such as dizziness, hyperventilation, and a sense of impending doom. The client’s ability to focus is greatly diminished, and they may have difficulty functioning.
Choice B rationale: Moderate anxiety involves a heightened sense of awareness and a narrowing of the perceptual field. The individual may experience physical symptoms such as increased heart rate, sweating, and muscle tension. They can still focus and problem-solve but may need assistance. The client’s symptoms of chest pain, headache, and shortness of breath, along with their emotional distress, align with moderate anxiety.
Choice C rationale: Mild anxiety is associated with a slight increase in alertness and perception. The individual may feel restless and have minor physical symptoms like slight muscle tension. They can still function effectively and use coping mechanisms to manage their anxiety.
Choice D rationale: Panic level anxiety is the most severe form and involves a complete disruption of the ability to function. The individual may experience extreme physical symptoms such as chest pain, palpitations, and a sense of losing control. They may be unable to communicate effectively or respond to their environment.
Each level of anxiety presents differently, and understanding these differences helps in providing appropriate care and interventions.
Correct Answer is ["B","C","D","F"]
Explanation
Choice B rationale:
Schizophrenia is a severe mental illness that is characterized by disturbances in thought, perception, emotion, and behavior. It is associated with an increased risk of suicide, with estimates suggesting that up to 10% of individuals with schizophrenia will die by suicide.
Several factors contribute to the increased risk of suicide in individuals with schizophrenia, including:
Hopelessness and despair: Individuals with schizophrenia often experience profound feelings of hopelessness and despair, which can lead to suicidal thoughts and behaviors.
Psychotic symptoms: Psychotic symptoms, such as delusions and hallucinations, can also contribute to suicide risk. For example, an individual with schizophrenia may experience auditory hallucinations that command them to harm themselves.
Impaired judgment: Schizophrenia can impair an individual's judgment and decision-making abilities, which can make it more difficult for them to resist suicidal urges.
Social isolation: Individuals with schizophrenia often experience social isolation, which can further increase their risk of suicide.
Comorbidity with other mental disorders: Schizophrenia is often comorbid with other mental disorders, such as depression and anxiety, which can also increase suicide risk.
Substance abuse: Substance abuse is a common problem among individuals with schizophrenia, and it can further increase suicide risk.
Choice C rationale:
Alcohol use disorder is a chronic, relapsing brain disease characterized by compulsive alcohol use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with alcohol use disorder are 10-14 times more likely to die by suicide than the general population.
Several factors contribute to the increased risk of suicide in individuals with alcohol use disorder, including: Depression: Alcohol use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Alcohol can impair judgment and increase impulsivity, which can lead to suicidal behaviors.
Social isolation: Alcohol use disorder can lead to social isolation, which can increase suicide risk.
Access to lethal means: Individuals with alcohol use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.
Choice D rationale:
Substance use disorder is a chronic, relapsing brain disease characterized by compulsive drug use, despite harmful consequences. It is a significant risk factor for suicide, with studies suggesting that individuals with substance use disorder are 6-12 times more likely to die by suicide than the general population.
Several factors contribute to the increased risk of suicide in individuals with substance use disorder, including: Depression: Substance use disorder is often comorbid with depression, which is a major risk factor for suicide. Impulsivity: Substance use can impair judgment and increase impulsivity, which can lead to suicidal behaviors.
Hopelessness: Individuals with substance use disorder may experience feelings of hopelessness and despair, which can increase suicide risk.
Social isolation: Substance use disorder can lead to social isolation, which can increase suicide risk.
Access to lethal means: Individuals with substance use disorder may have access to lethal means, such as firearms, which can increase the risk of suicide completion.
Choice F rationale:
Age greater than 65 years old is a risk factor for suicide. Suicide rates are highest among older adults, particularly white men over the age of 85.
Several factors contribute to the increased risk of suicide in older adults, including:
Chronic health conditions: Older adults are more likely to experience chronic health conditions, such as pain, disability, and cognitive decline, which can increase suicide risk.
Social isolation: Older adults are more likely to experience social isolation due to factors such as retirement, loss of loved ones, and decreased mobility.
Loss of independence: Older adults may experience a loss of independence due to physical and cognitive decline, which can contribute to suicide risk.
Access to lethal means: Older adults may have access to lethal means, such as firearms or medications, which can increase the risk of suicide completion.
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