A psychiatric nurse assesses a client who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder (OCD)?
Select one:
l keep reliving a car accident."
My legs often feel weak and spastic."
I am embarrassed to go out and speak in public."
l check where my car keys are eight times."
The Correct Answer is D
This comment indicates the possibility of obsessive-compulsive disorder (OCD) because it describes a repetitive behavior that may be a compulsion. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. In this case, the individual’s compulsion may be to repeatedly check the location of their car keys in order to reduce anxiety or distress.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Involuntary hospitalization for mental illness is typically reserved for situations where an individual poses an immediate danger to themselves or others due to a severe mental illness. In option A, the individual is experiencing command hallucinations, which are often a symptom of a severe mental illness such as schizophrenia. The fact that they want to hurt their neighbor is a clear indication that they pose a danger to others and require emergency intervention.
Option B may indicate a mental illness such as schizophrenia or bipolar disorder, but it does not necessarily pose an immediate danger to the individual or others.
Option C may indicate a relapse in addiction, but again, it does not necessarily pose an immediate danger to the individual or others.
Option D may indicate a need for follow-up and intervention, but it does not indicate an immediate danger to the individual or others.
Correct Answer is B
Explanation
The ethical principle of autonomy refers to an individual's right to make decisions about their own healthcare, treatment, and life choices. As a registered nurse, it is important to respect and promote the autonomy of patients. Option b best exemplifies the implementation of the ethical principle of autonomy because it involves exploring alternative solutions with the patient and allowing them to make their own choice among those alternatives. This approach respects the patient's right to make decisions about their own care, while also ensuring that they have the information they need to make an informed decision.
Option a suggests that the nurse is imposing their own decision on the patients, which violates the principle of autonomy.
Option c may involve staying with the patient to provide support and reassurance, but it does not necessarily involve promoting the patient's autonomy.
Option d involves intervening to prevent harm to the patient, which may be necessary at times but is not necessarily an example of promoting the patient's autonomy.

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