A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?
Provide information on stress reduction methods.
Assist the client to identify triggers to obsessive behaviors.
Speak to the client in a calm and soothing manner.
Assist the client in identifying his anxiety level.
The Correct Answer is B
Choice A reason: While providing information on stress reduction is helpful, it is not the immediate priority.
Choice B reason: Assisting the client to identify triggers is a priority as it directly addresses the cause of the OCD behaviors.
Choice C reason: Speaking to the client in a calm manner is supportive but does not address the underlying OCD behaviors.
Choice D reason: Identifying anxiety levels can be part of the intervention, but it is not as specific as identifying triggers for the OCD behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.
Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.
Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.
Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.
Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.
Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.
Correct Answer is A
Explanation
Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.
Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.
Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.
Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.
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