A nurse is caring for a newly admitted client who has obsessive-compulsive disorder and frequently performs ritualistic behaviors. The nurse should expect which of the following client responses if ritualistic behavior is restricted?
Replaces it with a different ritualistic behavior
Reports auditory hallucinations
Expresses relief from not having to perform the ritual
Experiences panic-level anxiety
The Correct Answer is D
Choice A rationale:
Replacing the ritual with a different ritualistic behavior is possible, but it does not necessarily predict the initial response when the restriction is first imposed.
Choice B rationale:
Reporting auditory hallucinations is not a typical response to restricting ritualistic behavior in someone with OCD.
Choice C rationale:
Expressing relief from not having to perform the ritual is unlikely, as ritualistic behaviors in OCD are often driven by distress and anxiety.
Choice D rationale:
If ritualistic behavior is restricted in an individual with obsessive- compulsive disorder (OCD), they may experience panic-level anxiety due to their inability to engage in their usual coping mechanism. OCD rituals are often performed to reduce anxiety, and restricting them can lead to increased distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Aspirin might increase the risk of bleeding, which is a concern during chemotherapy.
Choice B rationale:
Fiber intake should be increased to prevent constipation caused by chemotherapy.
Choice C rationale:
Applying heat to bruised areas might increase bleeding risk.
Choice D rationale:
Chemotherapy can lead to constipation, so taking a stool softenercan help prevent this side effect.
Correct Answer is D
Explanation
Choice A rationale:
This is not a priority intervention for a client who is in the manic phase of bipolar disorder. The nurse should monitor the client's vital signs as indicated, but blood pressure is not likely to be affected by mania unless the client has a preexisting condition or is taking medications that affect blood pressure.
Choice B rationale:
This is not an appropriate intervention for a client who is in the manic phase of bipolar disorder. The nurse should not restrict the client's physical activity, as this can increase their frustration and agitation. The nurse should provide a safe environment for the client to expend their energy and channel it into productive activities.
Choice C rationale:
This is not a suitable intervention for a client who is in the manic phase of bipolar disorder. The nurse should avoid stimulating the client's already elevated mood and arousal, as this can worsen their symptoms and increase their risk of injury or aggression. The nurse should limit the client's exposure to noise, crowds, and bright lights, and provide them with opportunities for rest and quiet time.
Choice D rationale:
A client who is in the manic phase of bipolar disorder has increased energy, activity, and metabolism, which can lead to weight loss and nutritional deficiencies. The nurse should provide the client with high-calorie finger foods that are easy to eat and do not require utensils or sitting down. This way, the nurse can help the client meet their nutritional needs while respecting their need for movement and autonomy.
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