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. An abdominal binder can be worn daily to reduce the protrusion: This is not an appropriate intervention for an umbilical hernia in an infant. Abdominal binders are typically used for support after abdominal surgeries or to manage hernias in adults.
B. This hernia is a normal variation that resolves without treatment: Umbilical hernias are common in infants and typically resolve on their own without intervention by around 1 to 2 years of age. Reassuring the mother about the benign nature of the hernia is appropriate.
C. The quarter should be secured with an elastic bandage wrap: Taping a quarter over the umbilicus is not a recommended treatment for an umbilical hernia and could pose a choking hazard to the infant.
D. Restrictive clothing will be adequate to help the hernia go away: Restrictive clothing is not an effective treatment for umbilical hernias in infants and could potentially cause discomfort or complications.
Correct Answer is D
Explanation
A. Marking the outline of the "olive-shaped" mass is important for diagnosis but is not the highest priority in pre-operative care.
B. Instructing parents regarding care of the incisional area is important but not the highest priority before surgery.
C.Monitoring feedings is important, but the primary concern is ensuring hydration and electrolyte balance, which may be compromised due to vomiting in pyloric stenosis.
D. IV fluids are essential to correct dehydration and electrolyte imbalances caused by vomiting in pyloric stenosis. This is the highest priority to stabilize the infant before surgery.
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