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A newly admitted client with obsessive-compulsive disorder (OCD) is performing ritualistic behaviors. What should the nurse do first?
- A. Discuss alternative coping strategies
- B. Identify precipitating factors for rituals
- C. Instruct on relaxation techniques
- D. Provide a structured activity schedule
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for rituals. This is the first step because understanding what triggers the client's rituals is crucial in developing an effective treatment plan. By identifying these factors, the nurse can address the root cause of the behavior and work towards reducing or eliminating it. Discussing coping strategies (A) may come later once the triggers are identified. Instructing on relaxation techniques (C) and providing a structured activity schedule (D) are helpful interventions but addressing the triggers takes precedence.
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A nurse is assessing a client who has schizophrenia. The client says, "I hear voices telling me what to do." This is an example of which of the following?
- A. Delusional disorder
- B. Associative looseness
- C. Hallucination
- D. Anhedonia
Correct Answer: C
Rationale: Auditory hallucinations are common in schizophrenia, involving hearing voices that are not real.
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
- A. Decrease anxiety
- B. Prevent aggressive and impulsive behaviors
- C. Manipulate others
- D. Decrease the time available for interaction with people
Correct Answer: A
Rationale: The correct answer is A: Decrease anxiety. The repetitive cleaning behavior in OCD is a manifestation of the client's attempt to reduce anxiety caused by intrusive thoughts or obsessions. This behavior provides temporary relief from anxiety by creating a sense of control. Choice B is incorrect because OCD cleaning behaviors are not primarily aimed at preventing aggressive or impulsive behaviors. Choice C is incorrect as the cleaning behavior is not typically a form of manipulation. Choice D is incorrect as the primary goal of the behavior is not to decrease interaction time but to manage anxiety.
A nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
- A. Limit the amount of time available to interact with others
- B. Focus attention on meaningful tasks
- C. Manipulate and control others’ behaviors
- D. Decrease anxiety to a tolerable level
Correct Answer: D
Rationale: The correct answer is D: Decrease anxiety to a tolerable level. In OCD, repetitive behaviors like picking up after others serve to reduce anxiety stemming from obsessive thoughts. This behavior acts as a coping mechanism to alleviate distress. Choice A is incorrect as the behavior is driven by anxiety, not a desire to limit interaction time. Choice B is incorrect as the behavior is not necessarily meaningful but rather a compulsive act. Choice C is incorrect as the behavior is self-directed, not aimed at controlling others.
A nurse on an inpatient eating disorders unit is caring for a client who has anorexia nervosa and has a body mass index of 17.2. Which of the following actions should the nurse take? (Select all that apply.)
- A. Provide the client with small meals frequently.
- B. Monitor the client's weight daily.
- C. Allow the client to choose the meals she will eat.
- D. Stay with the client during meals and for 1 hr afterward.
- E. Offer specific privileges for sustained weight gain.
Correct Answer: A, B, D, E
Rationale: The correct actions are A, B, D, and E.
A: Providing small meals frequently helps prevent overwhelming the client and supports gradual weight restoration.
B: Daily weight monitoring is crucial in tracking progress and ensuring the client's safety.
D: Staying with the client during meals and afterward helps prevent purging behaviors and offers support.
E: Offering privileges for sustained weight gain reinforces positive behavior and motivation for recovery.
Incorrect options:
C: Allowing the client to choose meals may lead to restrictive eating habits and hinder weight restoration.
F: No information given.
G: No information given.
A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the priority intervention for the nurse to make?
- A. Promote appropriate behavior during group therapy sessions.
- B. Encourage client input in the treatment plan.
- C. Communicate with the client using concrete language.
- D. Demonstrate assertive behavior.
Correct Answer: A
Rationale: The correct answer is A: Promote appropriate behavior during group therapy sessions. For a client with histrionic personality disorder, the priority intervention is to establish boundaries and promote appropriate behavior to ensure a therapeutic environment. This is crucial in managing attention-seeking behaviors and maintaining focus on the therapeutic goals. Encouraging client input in the treatment plan (B) is important but not the priority at this stage. Communicating with concrete language (C) may be helpful but does not address the immediate need for behavior management. Demonstrating assertive behavior (D) is not the priority as it may escalate the situation.