A client with obsessive-compulsive disorder (OCD. 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 while.

Teach the client thought-stopping techniques and how to refocus behaviors.

Assist the client to identify stimuli that precipitate the activity.

Allow time for the behavior and then redirect the client to other activities.

Answer and Explanation

The Correct Answer is D

Choice D is correct because allowing time for the behavior and then redirecting the client to other activities is an effective intervention for a client with OCD who is repeatedly washing the top of the same table. OCD is a disorder characterized by recurrent and intrusive thoughts (obsessions) and repetitive and ritualistic behaviors (compulsions) that cause distress and impairment. The nurse should not interfere with or criticize the client's compulsions, as this can increase anxiety and resistance. The nurse should instead set limits on the time and place for the compulsions and gradually reduce them by offering alternative coping strategies or distractions.

Choice A is incorrect because encouraging the client to be calm and relax for a while is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. The client may not be able to relax or stop their compulsions, as they are driven by irrational fears or beliefs that are difficult to control. The nurse should not minimize or dismiss the client's feelings, as this can make them feel misunderstood or invalidated.

Choice B is incorrect because teaching the client thought-stopping techniques and how to refocus behaviors is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. Thought-stopping techniques are cognitive strategies that aim to interrupt or replace negative or unwanted thoughts with positive or neutral ones. However, these techniques may not work for clients with OCD, as their obsessions are often persistent and resistant to change. The nurse should not attempt to teach new skills or challenge the client's thoughts during an acute episode of compulsion, as this can increase anxiety and frustration.

Choice C is incorrect because assisting the client to identify stimuli that precipitate the activity is not an effective intervention for a client with OCD who is repeatedly washing the top of the same table. The client may not be able to identify or avoid the triggers that cause their compulsions, as they are often internal or irrational. The nurse should not focus on finding the cause or meaning of the compulsions, as this can reinforce their significance or validity.

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Correct Answer is C

Explanation

Choice A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.

Choice B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.

Choice C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.

Choice D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.

A. Ask the pharmacist to add the Dextrose to a TPN solution. B. Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL. C. Push the undiluted Dextrose slowly through the currently infusing IV. D. Dilute the Dextrose in one liter of 0.9% Normal Saline solution.

Correct Answer is C

Explanation

Choice C is correct because pushing the undiluted Dextrose slowly through the currently infusing IV is the best way to administer the medication for a client with insulin shock. Insulin shock is a condition in which the blood glucose level drops too low due to excess insulin or insufficient food intake. This can cause symptoms such as confusion, sweating, tremors, or loss of consciousness. The nurse should administer 50% Dextrose IV as a bolus injection to raise the blood glucose level quickly and prevent brain damage.

Choice A is incorrect because asking the pharmacist to add the Dextrose to a TPN solution is not appropriate for a client with insulin shock. TPN stands for total parenteral nutrition, which is a type of intravenous feeding that provides all the nutrients needed by the body. TPN solutions contain dextrose, amino acids, lipids, vitamins, minerals, and electrolytes in specific concentrations and ratios. Adding extra dextrose to a TPN solution can alter its composition and cause complications such as hyperglycemia or fluid overload.

Choice B is incorrect because mixing the Dextrose in a 50 mL piggyback for a total volume of 100 mL is not effective for a client with insulin shock. A piggyback is a type of intravenous infusion that delivers medication through a secondary tubing attached to the primary tubing of another solution. Mixing the Dextrose in a piggyback can dilute its concentration and reduce its potency. It can also delay its delivery and onset of action.

Choice D is incorrect because diluting the Dextrose in one liter of 0.9% Normal Saline solution is not safe for a client with insulin shock. Normal Saline is a type of intravenous fluid that contains sodium chloride in isotonic concentration. Diluting the Dextrose in one liter of Normal Saline can lower its concentration and increase its volume significantly. This can cause complications such as hypoglycemia or fluid overload.

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A client with obsessive-compulsive disorder (OCD. is repeatedly washing the top of the same table. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?

Correct Answer is C

Explanation

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