The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?
Encourage the client to be calm and relax for a little while.
Teach the client thought stopping techniques and ways to refocus behaviors.
Assist the client to identify stimuli that precipitates the activity.
Allow time for the behavior and then redirect the client to other
The Correct Answer is D
A. Simply encouraging the client to be calm and relax may not be effective for someone with obsessive-compulsive disorder.
B.
Teaching techniques is more appropriate for structured therapy sessions rather than addressing compulsive behavior in the moment.
C. While identifying stimuli can be useful, it is not an immediate intervention.
D.
This approach respects the client’s need to complete the compulsion to reduce anxiety while gradually redirecting attention, minimizing distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Flaky, peeling skin (desquamation) occurs in later stages of scarlet fever, typically after the rash begins to fade. It is not an early sign of the disease.
B. A red, sandpaper-like rash that typically begins on the chest and spreads outward is one of the earliest indications of scarlet fever. This rash is caused by exotoxins produced by Streptococcus pyogenes and is a hallmark sign of the illness.
C. A white coating on the tongue, often followed by a characteristic “strawberry tongue,” develops later in the progression of scarlet fever rather than as an early symptom.
D. While fever is a common symptom of streptococcal infections, it is not the earliest indicator of scarlet fever. The rash usually appears within 12 to 48 hours of fever onset, making it a more specific early sign.
Correct Answer is A
Explanation
A. Determining the patient's need for pain medication is a priority to ensure the patient's comfort during the end-of-life care process. Pain management is a critical aspect of palliative care and should be addressed promptly.
B. Updating the nurse manager on the patient's status is important but is not the immediate priority. The nurse manager's awareness does not directly impact the patient's comfort or care at the moment of impending death.
C. Conveying the patient's status to the chaplain may be part of the holistic care approach and can provide spiritual support to the patient and family, but it is not the first priority in terms of the patient's immediate physical needs.
D. Documenting the impending signs of death is essential for legal and medical records; however, it is secondary to addressing the patient's immediate needs, such as pain relief.
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