A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse include?

Use detailed explanations when providing education to the client

Maintain a stimulating environment for the client

Provide the cant with a structured schedule of daily activities

Limit time for rituals to 20 min each day

Answer and Explanation

The Correct Answer is C

A. Use detailed explanations when providing education to the client: Providing detailed explanations can help the client better understand their condition and treatment, which is essential for managing obsessive-compulsive disorder (OCD). This intervention promotes client education and empowerment, enabling them to participate more effectively in their care and treatment.

B. Maintain a stimulating environment for the client: Individuals with OCD often benefit from a calm and organized environment rather than a stimulating one. A stimulating environment might exacerbate anxiety and OCD symptoms. Therefore, maintaining a calm and structured environment is typically more beneficial for clients with OCD.

C. Provide the client with a structured schedule of daily activities: Providing a structured schedule of daily activities can help regulate the client's routine and provide a sense of predictability, which can be comforting for individuals with OCD. A structured schedule can also help minimize the impact of OCD symptoms on daily functioning by providing a framework for completing tasks and managing time effectively.

D. Limit time for rituals to 20 minutes each day: Limiting time for rituals to a specific duration each day may not be appropriate or effective for all clients with OCD. While gradual exposure and response prevention (ERP) therapy may involve gradually reducing the time spent on rituals, setting a specific time limit may not address the underlying causes of OCD and could potentially increase anxiety and distress for the client.

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Correct Answer is C

Explanation

A. Administer a sedative medication: While sedation may be necessary in some cases to manage acute agitation or aggression, it should not be the first action taken. Administration of sedative medication requires a careful assessment of the client's condition, potential drug interactions, and individualized dosing considerations. It's important to consider less restrictive interventions before resorting to sedation.

B. Perform a debriefing with the staff: Debriefing with the staff is an essential step in processing the crisis situation and ensuring the well-being of the team. However, it should not be the first action taken when the client is in immediate danger of harming themselves or others.

C. Acknowledge the client's emotions: Acknowledging the client's emotions and validating their feelings can help establish rapport and de-escalate the situation. However, if the client is actively threatening self-harm or violence, addressing safety concerns should take precedence.

D. Place the client in restraints: Restraints should only be used as a last resort and when less restrictive interventions have failed to ensure the safety of the client and others. Restraints should not be the first action taken, especially if there are other interventions that can be attempted to de-escalate the situation.

A. Document the client's behavior once every hour. B. Keep the client in restraints until the prescription expires. C. Conduct a debriefing regarding the client with the unit staff D. Request an evaluation of the client within 12 hr of application of restraints

Correct Answer is C

Explanation

A. Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

C. Conducting a debriefing with the unit staff is crucial to evaluate the situation, discuss the events leading up to the use of restraints, and develop strategies to prevent the need for future restraint use. This helps ensure the safety and well-being of the client and others, as well as improve care practices.

D.Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

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A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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