A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take?

Encourage avoidance of situations that increase anxiety.

Investigate what situations precipitate anxiety.

Teach the client that compulsive behavior is excessive.

Prevent the client from performing compulsive behavior.

Answer and Explanation

The Correct Answer is B

Choice A reason : Encouraging avoidance of anxiety-increasing situations may seem beneficial, but it can reinforce OCD behaviors. Avoidance prevents the client from learning how to cope with anxiety and can limit their ability to participate in daily activities⁴.

Choice B reason : Investigating what situations precipitate anxiety is a crucial step in managing OCD. Understanding the specific triggers can help in developing strategies to cope with and eventually reduce the anxiety associated with these situations. This approach is aligned with cognitive-behavioral therapy principles, which are effective in treating OCD⁴⁵.

Choice C reason : Teaching the client that compulsive behavior is excessive is part of psychoeducation. However, simply telling a client that their behavior is excessive without providing coping mechanisms can be unhelpful and may increase their anxiety. It's important to combine this with therapeutic techniques that help the client manage their compulsions⁴.

Choice D reason : Preventing the client from performing compulsive behavior abruptly can cause significant distress and may not be feasible or safe. Instead, treatment usually involves gradual exposure to anxiety-provoking situations and learning to resist the urge to perform compulsions, a technique known as exposure and response prevention (ERP)⁴.

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Correct Answer is D

Explanation

Choice A reason : Anticoagulants are medications that prevent blood clots. They are not typically used to manage fluid volume excess in left-sided heart failure. Instead, they may be used if the patient has an increased risk of clotting due to reduced mobility or atrial fibrillation, which can be associated with heart failure⁵.

Choice B reason : Antiembolism stockings are used to prevent deep vein thrombosis (DVT) and are not directly related to the management of fluid volume excess. They may be used in heart failure patients to prevent DVT due to reduced mobility but do not aid in fluid reduction⁵.

Choice C reason : Oxygen therapy can be used in left-sided heart failure to alleviate symptoms of dyspnea due to pulmonary congestion. However, it does not directly reduce fluid volume excess. It is a supportive treatment to ensure adequate oxygenation⁵.

Choice D reason : Diuretics are the primary treatment for reducing fluid volume excess in left-sided heart failure. They work by increasing urine output, which helps to reduce the volume of fluid in the body and alleviate symptoms such as pulmonary edema and peripheral edema⁵.

A. Give morphine IV. B. Start an IV infusion of lactated Ringer's. C. Initiate cardiac monitoring. D. Administer oxygen therapy.

Correct Answer is D

Explanation

Choice A reason : While morphine IV can be used to alleviate pain and anxiety, it is not the first-line intervention for a pulmonary embolism. The primary concern in pulmonary embolism is to address the impaired gas exchange and potential hypoxemia¹.

Choice B reason : Starting an IV infusion of lactated Ringer's may be part of the overall management but is not the immediate priority. The initial focus should be on stabilizing the client's respiratory status¹.

Choice C reason : Initiating cardiac monitoring is important for observing the client's heart function, as pulmonary embolism can lead to strain on the heart. However, the first intervention should be to ensure adequate oxygenation¹.

Choice D reason : Administering oxygen therapy is the most critical initial intervention for a client with a pulmonary embolism. Oxygen therapy helps to manage hypoxemia and reduce the workload on the heart by improving oxygen saturation levels¹.

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A nurse is planning care for a client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, which of the following should the nurse anticipate using?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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