A client, who is newly admitted with Obsessive-Compulsive Disorder, washes their hands ritualistically before any activity. They arrive late to meals and does not have time to finish eating. The appropriate nursing action would be to:
interrupt the handwashing and insist the client come to meals with everyone else.
provide the client's meals later and after the other clients have eaten.
notify the client when it is 30 minutes before the meal so they can begin their handwashing.
allow the client to continue as is but provide them access to the kitchen.
The Correct Answer is D
a. Interrupt the handwashing and insist the client come to meals with everyone else. Interrupting ritualistic behaviors abruptly can increase distress and is not recommended. It may also reinforce the belief that the ritual is necessary.
b. Provide the client's meals later and after the other clients have eaten. This is not appropriate as it accommodates the OCD behavior and disrupts the mealtime routine for other clients.
c. Notify the client when it is 30 minutes before the meal so they can begin their handwashing. This is not appropriate as it enables the ritualistic behavior and may lead to increased anxiety if the client feels rushed to complete their ritual.
d. Allow the client to continue as is but provide them access to the kitchen. This is correct because it respects the client's autonomy while also providing an opportunity for gradual exposure therapy, where the client can work with the nurse to gradually reduce the time spent on rituals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. The unit can be managed with fewer staff. Seclusion requires close monitoring by staff.
b. Clients are encouraged to communicate with others. Seclusion is meant to be a temporary measure to prevent further harm, not necessarily to promote communication.
c. The reduced sensory input allows the client to regain control. Seclusion is a time-limited safety intervention used when a client poses a danger to themselves or others. It provides a safe space with reduced stimulation to allow the client to calm down and regain control.
d. Clients are forced to be responsible for themselves. Seclusion is not a punitive measure. The goal is to ensure safety and facilitate regaining control.
Correct Answer is D
Explanation
a. Akathisia and hypersalivation. These side effects are uncomfortable but generally not immediately life-threatening.
b. Dry mouth and urinary retention. These side effects are concerning and should be monitored, but they do not typically require immediate intervention unless severe.
c. Akinesia and insomnia. While akinesia (lack of movement) and insomnia are significant, they are not immediately life-threatening symptoms.
d. Sore throat, fever, and malaise. This choice is correct because these symptoms could indicate agranulocytosis, a potentially life-threatening side effect of clozapine that requires immediate medical intervention.
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