A nurse is contributing to the plan of care for a client who has obsessive-compulsive disorder (OCD) regarding brushing his teeth. The client brushes his tongue several times a day and has developed several ulcerations. Which of the following interventions should the nurse identify as a priority?
Provide information on stress reduction methods.
Assist the client to identify triggers to obsessive behaviors.
Speak to the client in a calm and soothing manner.
Assist the client in identifying his anxiety level.
The Correct Answer is B
Choice A reason: While providing information on stress reduction is helpful, it is not the immediate priority.
Choice B reason: Assisting the client to identify triggers is a priority as it directly addresses the cause of the OCD behaviors.
Choice C reason: Speaking to the client in a calm manner is supportive but does not address the underlying OCD behaviors.
Choice D reason: Identifying anxiety levels can be part of the intervention, but it is not as specific as identifying triggers for the OCD behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
Correct Answer is A
Explanation
Choice A reason: Keeping the environment warm can help prevent the vasoconstriction that can exacerbate PAD symptoms.
Choice B reason: Resting with the legs above heart level is not typically recommended for PAD as it can reduce arterial blood flow to the legs.
Choice C reason: Applying a heating pad is not recommended for clients with PAD because they may have decreased sensation and could suffer burns.
Choice D reason: Wearing antiembolic stockings during the day can help improve circulation, which is beneficial for clients with PAD.
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