A nurse is completing an admission assessment for a client who has obsessive- compulsive disorder and is becoming increasingly anxious. Which of the following actions should the nurse take first?

Teach the client about manifestations of anxiety.

Complete the client's assessment.

Provide reassurance of safety to the client.

Administer an anti-anxiety medication to the client.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.

Choice B rationale:

Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.

Choice C rationale:

Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.

Choice D rationale:

Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.

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Correct Answer is A

Explanation

Choice A rationale:

Postoperative pain management is crucial for the client's comfort and recovery.

Choice B rationale:

Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.

Choice C rationale:

Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.

Choice D rationale:

Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.

A. Allow the client autonomy in scheduling daily activities. B. Administer an antipsychotic medication to the client. C. Provide ample time for rituals in the early treatment stages. D. Initiate implosion therapy for the client.

Correct Answer is A

Explanation

Choice A rationale:

Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.

Choice B rationale:

Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.

Choice C rationale:

Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.

Choice D rationale:

Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.

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A nurse is completing an admission assessment for a client who has obsessive- compulsive disorder and is becoming increasingly anxious. Which of the following actions should the nurse take first?

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