A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, "I'm feeling sad. I don't want to talk now." Which of the following responses should the nurse make?

A. Focusing attention on useful tasks: While the client's actions involve tasks, the primary motivation is to reduce anxiety rather than simply focusing attention on useful tasks for their own sake.

B. Manipulating and controlling others' behavior: The client's behavior is more related to managing their own anxiety through compulsive actions rather than manipulating or controlling others.

C. Decreasing anxiety to a tolerable level.
In obsessive-compulsive disorder (OCD), individuals often engage in repetitive and ritualistic behaviors as a way to manage anxiety. The compulsive behaviors, such as cleaning and picking up after others in this case, serve as a mechanism to reduce anxiety or prevent a feared event. These actions may provide a sense of control and temporary relief from obsessive thoughts.

D. Limiting the amount of time available for interaction with others: While the client's compulsive behaviors may limit social interactions, the primary purpose is to manage anxiety rather than intentionally limiting interaction with others.

A. "Avoid foods that contain tyramine" is not relevant to fluoxetine. Tyramine restriction is a concern with certain medications, such as monoamine oxidase inhibitors (MAOIs), but not with SSRIs like fluoxetine.

B. "Plan to discontinue this medication as soon as your depression is relieved" is not advisable. Discontinuing an antidepressant abruptly can lead to withdrawal symptoms and may not allow for the full resolution of depressive symptoms. The decision to discontinue medication should be made in consultation with a healthcare provider.

C. "Expect that your mood might take one to three weeks to begin improving" is a crucial piece of information to provide because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), often takes a few weeks to start exerting its therapeutic effects. It's important for the client to understand that the full benefits of the medication may not be felt immediately.

D. "Stop taking this medication if weight loss or gain occurs" is not an appropriate instruction. Weight changes are potential side effects of fluoxetine, but the decision to continue or discontinue the medication should be based on consultation with a healthcare provider. Abruptly stopping medication without medical guidance can lead to withdrawal symptoms and is not recommended.