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A client with obsessive-compulsive disorder (OCD) spends hours each day washing her hands. Which intervention should the nurse implement to help the client reduce this behavior?
- A. Encourage the client to set a time limit for washing hands.
- B. Encourage the client to wash hands only when necessary.
- C. Encourage the client to use hand sanitizer instead of washing.
- D. Encourage the client to explore the reasons behind the hand washing.
Correct Answer: A
Rationale: Setting a time limit for hand washing is an effective intervention in managing obsessive-compulsive disorder (OCD) symptoms. By establishing boundaries around the behavior, the client can gradually work towards reducing the excessive hand washing and regaining control over the compulsion. Choice B is not as effective because it does not address the underlying compulsion. Choice C may not be helpful as it may not satisfy the client's need for cleanliness and could reinforce the behavior. Choice D, while important in therapy, may not be the most immediate intervention needed to address the excessive hand washing behavior.
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After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, 'You are incompetent!' Which is the nurse's best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. I'll give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: In this scenario, the most appropriate response for the nurse is option B. By acknowledging the client's feelings and setting a boundary regarding inappropriate behavior, the nurse addresses the situation with empathy. This response demonstrates understanding of the client's emotions while also maintaining a professional standard by expressing discomfort with swearing. Option A could come off as defensive and may escalate the situation. Option C may be perceived as condescending and not immediately address the client's behavior. Option D, although offering space, does not directly address the inappropriate behavior and misses an opportunity to set a professional boundary.
A client is being treated for obsessive-compulsive disorder (OCD). Which intervention should be included in the care plan?
- A. Discourage the client from performing rituals.
- B. Allow the client to perform rituals in the early stages of treatment.
- C. Encourage the client to focus on their compulsions.
- D. Isolate the client to prevent performance of rituals.
Correct Answer: B
Rationale: Allowing the client to perform rituals in the early stages of treatment is a common therapeutic approach for obsessive-compulsive disorder (OCD). Allowing the client to engage in rituals can help reduce anxiety by providing temporary relief. It is a part of exposure therapy, where the individual is gradually exposed to anxiety-provoking situations. As treatment progresses, the focus shifts to gradually reducing the frequency and intensity of rituals through interventions like exposure and response prevention therapy. Discouraging the client from performing rituals (Choice A) is not recommended as it may increase anxiety and resistance to treatment. Encouraging the client to focus on their compulsions (Choice C) may reinforce the behavior rather than helping to decrease it. Isolating the client (Choice D) is not therapeutic and can lead to feelings of abandonment and worsen symptoms.
When educating the family of a client diagnosed with dissociative identity disorder, which of the following instructions should the nurse include?
- A. Encourage the client to avoid stressful situations.
- B. Encourage the client to participate in daily activities.
- C. Encourage the client to express their feelings.
- D. Encourage the client to develop a daily routine.
Correct Answer: D
Rationale: In cases of dissociative identity disorder, it is beneficial for the client to establish a daily routine. This structure can enhance symptom management and provide a sense of stability, which is particularly important for individuals with this condition. Encouraging the client to avoid stressful situations (Choice A) may not always be possible and does not address the need for structure. While encouraging the client to participate in daily activities (Choice B) is important, having a routine is more crucial for managing dissociative identity disorder. Expressing feelings (Choice C) is valuable but establishing a routine takes precedence in this situation.
A client has been diagnosed with borderline personality disorder. Which behavior is characteristic of this disorder?
- A. Excessive need for attention
- B. Instability in relationships
- C. Fear of abandonment
- D. Lack of interest in activities
Correct Answer: B
Rationale: The correct answer is B: Instability in relationships. Individuals with borderline personality disorder often exhibit instability in their relationships, characterized by intense and unstable interpersonal connections, oscillating between idealization and devaluation. This pattern can lead to frequent conflicts, dramatic emotional shifts, and difficulties maintaining stable relationships. Choices A, C, and D are incorrect. While individuals with borderline personality disorder may also have an excessive need for attention, fear of abandonment, or lack of interest in activities, the hallmark feature defining this disorder is the instability in relationships.
A healthcare professional is assessing a client who has been diagnosed with major depressive disorder. Which symptom should the healthcare professional expect to observe?
- A. Increased energy
- B. Weight gain
- C. Increased appetite
- D. Restlessness
Correct Answer: B
Rationale: Weight gain is a common symptom of major depressive disorder. Individuals with major depressive disorder often experience changes in appetite, leading to weight gain or loss. This symptom is related to disruptions in the individual's eating habits and metabolism, which are commonly associated with depression. Choices A, C, and D are incorrect because increased energy, increased appetite, and restlessness are not typical symptoms of major depressive disorder. In fact, individuals with depression often experience fatigue, changes in appetite, and feelings of restlessness or agitation.