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A nurse is caring for a newly admitted client who has obsessive-compulsive disorder.
Which of the following actions should the nurse take first? .

Administer an antianxiety medication

Calculate the client's score on the Hamilton Rating Scale for Anxiety.

Explain the use of response prevention to the client.

Discuss the benefits of relaxation exercises with the client.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.

Choice B rationale:

Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.

Choice C rationale:

Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.

Choice D rationale:

Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.

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Correct Answer is B

Explanation

Choice A rationale:

A consistent state of depression is not indicative of delirium, but rather a mood disorder.

Choice B rationale:

Fluctuating levels of orientation are a hallmark sign of delirium and should be reported to the provider.

Choice C rationale:

Obsessive behaviors are not typically associated with delirium, but may be indicative of an anxiety disorder.

Choice D rationale:

Gradual memory loss is more indicative of dementia, not delirium, which is typically a sudden onset.

A. Obtain a prescription for haloperidol. B. Take the client to the seclusion room. C. Verbally de-escalate the client. D. Place the client in restraints.

Correct Answer is C

Explanation

Choice A rationale:

Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.

Choice B rationale:

Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

Choice C rationale:

Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.

Choice D rationale:

Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

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A nurse is caring for a newly admitted client who has obsessive-compulsive disorder.
Which of the following actions should the nurse take first? .