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 B

Explanation

Choice A reason : While helping the client identify positive personality traits can be beneficial for self-esteem and long-term recovery, it is not the immediate priority during the acute withdrawal phase. The focus during this time should be on managing withdrawal symptoms and ensuring the client's safety¹.

Choice B reason : Providing for adequate hydration and rest is the priority intervention for a client in alcohol withdrawal. Withdrawal can lead to significant fluid loss due to vomiting and sweating, and rest is essential for the body to recover from the physiological stress of detoxification. Ensuring the client is well-hydrated and rested can prevent complications and aid in the recovery process¹².

Choice C reason : Educating the client about the consequences of alcohol misuse is an important part of treatment but is not the immediate priority during withdrawal. Education is more effective when the client is stable and can participate actively in learning and discussion¹.

Choice D reason : Confronting the use of denial and other defense mechanisms may be part of the therapeutic process but is not the immediate priority during the acute phase of withdrawal. The nurse's immediate concern should be the physical stabilization of the client¹.

A. Ecchymosis of the extremities B. Straw-colored urine C. Tenderness in the left upper abdomen D. Clay stools

Correct Answer is D

Explanation

Choice A reason : Ecchymosis of the extremities is not a typical finding associated with common bile duct obstruction. It refers to bruising, which can have many causes unrelated to bile duct issues⁴.

Choice B reason : Straw-colored urine is usually a sign of well-hydrated and healthy individuals. In the case of common bile duct obstruction, the urine may actually become darker due to increased bilirubin levels⁴.

Choice C reason : Tenderness in the left upper abdomen is more commonly associated with issues related to the stomach, spleen, or pancreas, not the common bile duct⁴.

Choice D reason : Clay stools are a classic symptom of common bile duct obstruction. When bile flow is blocked, stools can lose their normal brown color and appear pale or clay-colored due to the absence of bilirubin⁴.

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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 in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder and is currently in withdrawal. Which of the following interventions should the nurse identify as the priority?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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