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 B
Explanation
Choice A rationale:
Frequent cervical examinations may increase the risk of introducing infection or causing additional bleeding. Cervical examinations are not a priority in managing placental abruption.
Choice B rationale:
Placental abruption can lead to significant blood loss, and the client may require intravenous fluids and blood products to maintain hemodynamic stability. Initiating an IV with an 18-gauge catheter allows for rapid administration of fluids and blood products if needed.
Choice C rationale:
Monitoring fetal heart rate hourly is important, but addressing the mother's hemodynamic stability with IV fluids takes priority.
Choice D rationale:
Vital signs should be obtained more frequently than every 4 hours due to the risk of ongoing blood loss.
Correct Answer is B
Explanation
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
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