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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : Bubbling in the water seal chamber with exhalation can be a normal finding as it indicates that air is being evacuated from the pleural space. However, continuous bubbling may suggest an air leak, which should be evaluated.
Choice B reason : The visibility of the eyelets is not typically a concern unless the tube is dislodged. If the chest tube is functioning properly and the eyelets are meant to be within the chest cavity, their visibility might indicate dislodgement.
Choice C reason : Crepitus, or subcutaneous emphysema, can occur if air leaks into the tissue surrounding the insertion site. This can be a sign of a problem with the chest tube placement or function and should be reported to the provider immediately.
Choice D reason : Movement of the trachea toward the unaffected side, or tracheal deviation, can be a sign of tension pneumothorax, a life-threatening condition that requires immediate attention.
Correct Answer is C
Explanation
Choice A reason : Decreasing the client's carbohydrate intake is not typically a priority intervention for cirrhosis and ascites. While managing overall nutrition is important, carbohydrates are a necessary component of a balanced diet and provide essential energy¹.
Choice B reason : Increasing the client's saturated fat intake is not recommended in cirrhosis and ascites. Saturated fats can contribute to fatty liver disease and worsen liver function. A diet low in saturated fats and high in omega-3 fatty acids is generally advised¹.
Choice C reason : Decreasing the client's fluid intake is a key intervention for managing ascites in cirrhosis. Ascites is the accumulation of fluid in the peritoneal cavity, and reducing fluid intake can help manage this condition. The goal is to prevent further fluid accumulation and reduce the risk of complications such as spontaneous bacterial peritonitis¹².
Choice D reason : Increasing the client's sodium intake is not advised for cirrhosis and ascites. Sodium can cause the body to retain water, exacerbating fluid accumulation in the abdomen. A low-sodium diet is typically recommended to help control ascites¹.
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