A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

The client's attempt to decrease anxiety.

The client's wish to decrease the time available for interaction with others.

The client's unconscious need to manipulate others.

The client's delusion that cleaning is necessary.

Answer and Explanation

The Correct Answer is A

As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.

Choice B, the client's wish to decrease the time available for interaction with others, is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.

Choice D, the client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.

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Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

A. Oxygen saturation. B. Blood pressure. C. Level of consciousness. D. Assessment for nausea.

Correct Answer is B

Explanation

When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension. Oxygen saturation, choice A, may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness, choice C, and assessment for nausea, choice D, may also be important but are not the priority assessments in this situation.

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A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A patient with heart failure has met with their primary provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the patient begins treatment, which assessment should the nurse prioritize?

Correct Answer is B

Explanation

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A nurse is caring for a client who has obsessive-compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

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A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?

The nurse is collecting data from a client with obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)