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 D
Explanation
Choice A reason: Signal anxiety refers to a specific concern or perceived threat, which is not indicated by the patient's statement.
Choice B reason: Severe anxiety is a high level of anxiety that would likely impair functioning, which cannot be determined from the patient's statement alone.
Choice C reason: Moderate anxiety is a manageable level of anxiety, but the patient's statement suggests a more pervasive and non-specific anxiety.
Choice D reason: Free-floating anxiety is a general feeling of dread or foreboding that is not attached to any specific issue or situation, which aligns with the patient's expression of a vague sense of impending doom.
Correct Answer is A
Explanation
Choice A reason: The 'thinking/content of thought' section of the Mental Health Status Examination assesses the logical process of thought, presence of delusions, obsessions, and preoccupations.
Choice B reason: 'Memory' assesses the person's ability to recall past events, which is not directly related to their current thought content.
Choice C reason: 'Judgment' evaluates the ability to make reasoned decisions, which, while important, is distinct from the content of thought.
Choice D reason: 'Speech and the ability to communicate' assesses the clarity, relevance, and coherence of speech, not the internal thought process.
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