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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Redirecting the sibling’s concern to the patient minimizes and dismisses the sibling’s anxiety. This is not therapeutic.
Choice B reason: Schizophrenia has a genetic component, especially in identical twins, but environment and other factors also play roles. This response provides accurate information while reducing unnecessary fear.
Choice C reason: Offering referral may be helpful later, but it does not immediately address the sibling’s expressed concern or provide reassurance.
Choice D reason: Saying there is a 50-50 chance is inaccurate and unnecessarily alarming. The risk is higher in identical twins but not absolute.
Correct Answer is A
Explanation
Choice A reason: The id represents instinctual drives and seeks immediate gratification without considering consequences or rules. The client’s impulsive action of taking food despite prohibitions reflects id dominance.
Choice B reason: The ego mediates between the id and reality, considering consequences before acting. If the ego were driving the behavior, the client would have sought food in a more socially acceptable way.
Choice C reason: The superego governs moral standards and conscience. If this were guiding behavior, the client would have restrained themselves from taking others’ food.
Choice D reason: The conscious mind represents awareness of current thoughts and actions, not instinctual drives. The described behavior is better explained by the unconscious id.
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