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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Calling the surgeon to talk to the patient may be helpful in some cases, but it does not directly address the patient's immediate emotional needs. The surgeon can provide detailed information about the procedure, which might alleviate some fears, but this is not always the immediate solution.

Choice B reason:

Offering to call the chaplain for the patient could provide emotional and spiritual support, which is important in holistic care. However, this should be done in addition to addressing the patient's concerns about the surgery itself.

Choice C reason:

Informing the patient that the survival rate for this surgery is very high directly addresses the patient's fear about not surviving the surgery. Providing factual reassurance about the success rate can help to alleviate anxiety and is an appropriate immediate response.

Choice D reason:

Recommending analgesics only during surgery does not address the patient's expressed fear and is not an appropriate response to the emotional concern. Analgesics are for pain management and do not provide reassurance about the outcome of the surgery.

A. Notify the physician. B. Evaluate the distal pulses. C. Have the patient lie in bed with a pillow under the knees. D. Cover the patient with a blanket.

Correct Answer is B

Explanation

Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.

Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.

Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.

Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting in the care of a preoperative patient. The patient states, "I'm really afraid that I won't make it through the surgery." Which action by the nurse is appropriate?

Correct Answer is C

Explanation

A patient with peripheral arterial disease (PAD) is sitting in a chair and has cool feet that are reddish-purple in color. What action should the nurse take?

Correct Answer is B

Explanation

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