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 D
Explanation
A. Securing the chest tube to the stretcher is important, but not the most critical action as it does not directly affect the function of the chest tube during transport.
B. Administering pain medication is important for comfort but is not the most immediate concern during urgent transport for a CT scan.
C. Marking the amount of chest drainage is a routine monitoring action and can be done before or after transport, thus not the most critical action.
D. Keeping the chest tube container below the site of insertion is crucial to maintain proper
drainage by gravity and prevent complications such as tension pneumothorax, which can be life- threatening.
Correct Answer is D
Explanation
A. Client's healthcare power of attorney - This is important legal information but not the most immediate concern for the healthcare provider.
B. Currently prescribed medications - While important, this information does not represent an immediate change in the client's condition.
C. Fall at home as reason for admission - This is background information and, although important, is not the most pressing issue if the client's condition is worsening.
D. Increasing confusion of the client - The increasing confusion could indicate a change in the client's baseline mental status, which could be a sign of a serious condition such as a subdural hematoma or infection and should be communicated immediately.
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