A client diagnosed with Obsessive-Compulsive Disorder has developed a number of compulsive washing rituals over the years. The nurse recognizes that these behavioral rituals serve which purpose?

Draws attention and approval from significant others.

Provides temporary and partial relief from anxiety.

Increases the inhibitory powers of their superego.

Blocks delusions and hallucinations from awareness.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Draws attention and approval from significant others.

This statement is incorrect. Compulsive washing rituals in Obsessive-Compulsive Disorder (OCD) are not typically performed to draw attention or gain approval from others. Instead, these rituals are driven by an internal need to reduce anxiety and distress associated with obsessive thoughts. The primary function of these behaviors is to manage the individual’s own anxiety rather than to seek external validation.

Choice B Reason:

Provides temporary and partial relief from anxiety.

This is the correct response. Compulsive washing rituals in OCD are performed to alleviate the intense anxiety and distress caused by obsessive thoughts. Although the relief is temporary and partial, it reinforces the behavior, creating a cycle where the individual feels compelled to repeat the ritual to manage their anxiety. This temporary relief is a key characteristic of compulsive behaviors in OCD.

Choice C Reason:

Increases the inhibitory powers of their superego.

This statement is incorrect. The concept of the superego is related to Freud’s psychoanalytic theory, where it represents the internalized moral standards and ideals. Compulsive washing rituals in OCD are not performed to increase the inhibitory powers of the superego but rather to reduce anxiety and distress. The rituals are a response to obsessive thoughts rather than a means of enhancing moral inhibition.

Choice D Reason:

Blocks delusions and hallucinations from awareness.

This statement is incorrect. Delusions and hallucinations are more commonly associated with psychotic disorders, such as schizophrenia, rather than OCD. Compulsive washing rituals in OCD are not intended to block delusions or hallucinations but to manage anxiety related to obsessive thoughts. The focus of these rituals is on reducing distress rather than addressing psychotic symptoms.

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Correct Answer is B

Explanation

Choice B Reason: Assess for environmental triggers and potential unmet needs.

Choice A Reason:

Consulting the interdisciplinary team regarding behavior modification techniques is important for long-term management of behavioral problems in clients with major neurocognitive disorder. However, it is not the immediate priority when a client is exhibiting acute behavioral escalation. Immediate assessment and intervention are necessary to address the current situation and ensure the client’s safety.

Choice B Reason:

Assessing for environmental triggers and potential unmet needs is the priority in this scenario. Clients with major neurocognitive disorder often exhibit behavioral problems due to unmet needs or environmental factors that they cannot communicate effectively. Identifying and addressing these triggers can help de-escalate the situation and prevent further agitation. This approach aligns with evidence-based practice, which emphasizes understanding the underlying causes of behavioral issues to provide appropriate interventions.

Choice C Reason:

Assessing for potential injury to the client’s arms, legs, and back is crucial, especially if the client is on the ground and exhibiting aggressive behavior. However, this assessment should follow the initial step of identifying and addressing environmental triggers and unmet needs. Ensuring the client’s immediate safety by understanding the cause of their behavior is the first priority.

Choice D Reason:

Anticipating the behavior and physically restraining the client when pacing begins is not recommended as the first line of action. Physical restraint should be a last resort due to the potential for causing harm and increasing the client’s agitation. Instead, non-pharmacological interventions, such as identifying triggers and unmet needs, should be prioritized to manage the behavior safely and effectively.

A. Word salad. B. Loose association. C. Clang association. D. Ideas of reference.

Correct Answer is C

Explanation

Choice A Reason:

Word salad.

Word salad refers to a jumble of words and phrases that lack logical coherence, often seen in severe cases of schizophrenia. The speech is typically incomprehensible and does not follow any recognizable pattern. In this case, the client’s response, while unusual, follows a pattern based on sound rather than meaning, which does not fit the definition of word salad.

Choice B Reason:

Loose association.

Loose association involves a series of thoughts that are only loosely connected to each other. This is a common symptom in schizophrenia, where the person’s thoughts may drift from one topic to another with little logical connection. However, the client’s response in this scenario is more structured and based on rhyming, which is characteristic of clang associations rather than loose associations.

Choice C Reason:

Clang association.

Clang association is a type of thought disorder where the person’s speech is governed by the sound of words rather than their meaning. This often results in rhyming or punning speech. The client’s response, “A match is a catch. A catch is a batch. The batch started to hatch,” is a clear example of clang association because the words are linked by their similar sounds rather than their meanings.

Choice D Reason:

Ideas of reference.

Ideas of reference involve the belief that ordinary events, objects, or behaviors of others have particular and unusual significance specifically for the person. This is often seen in paranoid schizophrenia. The client’s response does not indicate that they believe the words have special personal significance; instead, it shows a pattern of rhyming, which is more indicative of clang association.

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A client diagnosed with Obsessive-Compulsive Disorder has developed a number of compulsive washing rituals over the years. The nurse recognizes that these behavioral rituals serve which purpose?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems. At the change of shift, the client’s behavior escalates from pacing in the hallway to screaming and waving their arms while on the ground. Which of the following represents a priority for the nurse?

Correct Answer is B

Explanation

The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?

Correct Answer is C

Explanation

A nurse is teaching a class about manual therapies. The nurse should include that which of the following treatments is part of chiropractic medicine?

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