A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?
Plan the client's schedule to allow time for rituals.
Confront the client about the senseless nature of the repetitive behaviors.
isolate the client for a period of time.
Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
The Correct Answer is A
A. Plan the client's schedule to allow time for rituals.
Explanation:
For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.
Why the other choices are incorrect:
B. Confront the client about the senseless nature of the repetitive behaviors.
Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.
C. Isolate the client for a period of time.
Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.
D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.Lithium is excreted through the kidneys, and dehydration and sodium depletion increase the risk of lithium toxicity. A client who runs 4 miles outdoors every afternoon is at risk of excessive sweating and fluid loss, which can lead to dehydration and sodium depletion. This reduces lithium excretion, leading to toxic levels in the blood.
B. Anormal sodium intake helps maintain lithium balance. A low sodium intake increases lithium retention, but 2-3 grams/day is within the normal recommended range.
C. Adequate hydration helps prevent lithium toxicity. Clients on lithium should drink 2–3 liters of fluid daily to promote kidney function and lithium excretion.
D. Tyramine-rich foods (e.g., aged cheese, cured meats) are a concern for clients on monoamine oxidase inhibitors (MAOIs), not lithium. Tyramine does not affect lithium levels.
Correct Answer is A
Explanation
A. "I need to make sure that the potential victim is warned."
Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.
B. "I need to keep the information confidential due to the client's right to privacy."
Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.
C. "I can only discuss the client's threats with a court order."
Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.
D. "I should verbally report this information to the psychiatrist."
Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.
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