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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 A

Explanation

Choice A rationale:

Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.

Choice B rationale:

Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.

Choice C rationale:

Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.

Choice D rationale:

Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.

A. Reinforce teaching on the client's use of coping skills B. Encourage the client to use personal support systems. C. Assist with a client referral for social services. D. Identify if the client has thoughts of self-harm.

Correct Answer is D

Explanation

Choice A rationale:

Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.

Choice B rationale:

Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.

Choice C rationale:

Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.

Choice D rationale:

Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.

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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? .

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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? .