A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care?

A. Provide a structured activity schedule for the client: While providing a structured activity schedule can be beneficial for clients with OCD, it may not be the first action the nurse should take. Before implementing such a schedule, it is essential to understand the underlying factors contributing to the client's ritualistic behaviors.

B. Identify precipitating factors for ritualistic behaviors: This is the first action the nurse should take when caring for a client with OCD. By identifying the triggers or precipitating factors that lead to the client's ritualistic behaviors, the nurse can develop a targeted plan of care to address these specific triggers and help the client manage their symptoms more effectively.

C. Instruct the client on relaxation techniques for use when anxiety increases: While relaxation techniques can be helpful for managing anxiety associated with OCD, identifying precipitating factors should be addressed first to understand the specific triggers contributing to the client's anxiety and ritualistic behaviors.

D. Discuss alternative coping strategies with the client: Exploring alternative coping strategies is an important aspect of caring for clients with OCD, but it should come after identifying precipitating factors. Once triggers are identified, the nurse and client can collaboratively develop and implement alternative coping strategies tailored to the client's specific needs and triggers.

A. "Who is lying about you and trying to poison you?": This response may come across as confrontational and may not effectively address the client's underlying fear or paranoia. It could potentially escalate the client's anxiety or reinforce their delusions by implying that the nurse believes the accusations are valid.

B. "You seem to be having very frightening thoughts.": This response acknowledges the client's experience without directly challenging or validating the content of their delusions. It conveys empathy and concern while also opening the door for further exploration of the client's feelings and experiences. By acknowledging the frightening nature of the client's thoughts, the nurse demonstrates understanding and provides an opportunity for therapeutic dialogue.

C. "You are mistaken. Nobody is lying about you or trying to poison you.": This response denies the client's reality and contradicts their experience, which can be invalidating and may cause the client to feel misunderstood or dismissed. It's important to avoid outright denial of the client's beliefs, as it can damage the therapeutic relationship and hinder effective communication.

D. "Why do you think you are being lied about and poisoned?": While this response seeks to explore the client's thoughts and feelings, it may be perceived as challenging or confrontational. It could unintentionally reinforce the client's delusions by inviting them to elaborate on their paranoid beliefs without first acknowledging the distress they are experiencing.