The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? (Select all that apply.)

Refrain from judgmental comments about counting magazines.

Teach the client how to use the technique of thought stopping.

Assist the client to identify circumstances that increase anxiety.

Remove magazines from the commons room when the client attends a group activity.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason: Avoiding judgmental remarks supports therapeutic rapport and prevents worsening anxiety or defensiveness.

Choice B reason: Teaching coping strategies like thought stopping helps the client begin to manage obsessive behaviors more effectively.

Choice C reason: Identifying triggers for obsessive behaviors allows the nurse and client to develop strategies for prevention and management.

Choice D reason: Removing magazines to prevent counting avoids addressing the underlying compulsion and may increase anxiety. This approach is not appropriate in the initial care plan.

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Correct Answer is A

Explanation

Choice A reason: Redirecting the focus back to the patient in a therapeutic and nonjudgmental way ensures the conversation remains centered on the client’s needs. This maintains professional boundaries while being supportive.

Choice B reason: Stating that nurses direct interviews is authoritative and may come across as rigid. It does not encourage patient openness.

Choice C reason: Responding with a prohibition sounds harsh and judgmental. It could damage rapport and shut down communication.

Choice D reason: Asking "why" can make the patient feel defensive, which is not therapeutic. It shifts the focus to justification rather than reflection.

A. Engage other staff members to remove the client from the bathroom. B. Give a reminder that the client has been cleaning the bathroom for 1.5 hours and it is time to take a break. C. Tell the client that the bathroom is very clean and that this behavior is unreasonable. D. Tell the roommate to use the shower in another location.

Correct Answer is B

Explanation

Choice A reason: Forcibly removing the client escalates anxiety and can increase resistance. This action does not support therapeutic management of OCD.

Choice B reason: Providing a clear, respectful, and time-limited reminder supports structure and helps the client redirect behavior without confrontation. It balances therapeutic boundaries with empathy.

Choice C reason: Dismissing the client’s concern as unreasonable invalidates their experience, increasing defensiveness and mistrust. This does not support treatment goals.

Choice D reason: Avoiding the problem by redirecting the roommate fails to address the client’s compulsive behavior and disrupts the care environment.

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The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an interview, a patient attempts to shift the focus from self to the nurse by asking personal questions. The nurse should respond by saying:

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A nurse observes a hospitalized client grabbing snacks from other patients' trays, despite being told not to. When confronted, the client says, "I was hungry, so I took it." Based on Freud's psychoanalytic theory, which part of the personality is most likely influencing the client's behavior?

A client is exhibiting signs of severe anxiety, including hyperventilation, restlessness, and difficulty concentrating. Which communication approach should the nurse use to effectively support the client during this crisis?

A nurse working in a psychiatric unit discovers that a client has disclosed intentions to harm a specific person outside the hospital. Balancing ethical principles, what is the nurse’s most appropriate action?

A client in the psychiatric unit is experiencing severe anxiety—they are trembling, pacing, and saying, "I can’t think straight. I feel like something terrible is going to happen." Which of the following is the most therapeutic response by the nurse?

A nurse is assessing a client diagnosed with schizophrenia who is exhibiting positive symptoms. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse practicing Peplau’s Relations Theory is working with a newly admitted client who is withdrawn and reluctant to engage. According to Peplau’s working model, which nurse action best explains the orientation phase of the nurse-client relationship?

A nurse is caring for a client newly prescribed aripiprazole, a third-generation antipsychotic, for the treatment of schizophrenia. Which nursing observation would require the most immediate intervention?