A patient is being treated on the mental health unit for an anxiety disorder. The patient approaches the nurse and reports feeling dizzy and weak, with a sensation of a racing heart. The nursing care plan includes interventions of imagery exercises and as-needed lorazepam (Ativan) for symptoms of anxiety. What should the nurse do first?

Obtain the patient's vital signs.

Give the patient the prescribed as-needed lorazepam.

Instruct the patient to sit and breathe deeply.

Instruct the patient in an imagery exercise.

Answer and Explanation

The Correct Answer is A

Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.

Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.

Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.

Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.

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Correct Answer is A

Explanation

Choice A reason: Assessing the client's level of anxiety is crucial as it can inform the nurse about the severity of the OCD symptoms and guide further interventions.

Choice B reason: Interrupting compulsive behavior abruptly can cause significant distress to the client and is not recommended without proper behavioral therapy techniques.

Choice C reason: Negative reinforcement techniques are not typically used in OCD management as they can exacerbate anxiety and are not considered therapeutic.

Choice D reason: Encouraging avoidance of anxiety-increasing situations may reinforce OCD behaviors and is not a recommended approach. Exposure and response prevention, a type of cognitive-behavioral therapy, is often used instead.

A. The client's unconscious need to manipulate others B. The client's delusion that cleaning is necessary C. The client's wish to decrease the time available for interaction with others D. The client's attempt to decrease anxiety

Correct Answer is D

Explanation

Choice A reason: OCD is not characterized by an unconscious need to manipulate others but by anxiety-driven compulsions.

Choice B reason: While clients with OCD may feel a need to clean due to contamination fears, it is not a delusion but rather an obsession that drives the compulsion.

Choice C reason: The repetitive cleaning is not typically a conscious choice to decrease social interaction but a compulsion to alleviate anxiety.

Choice D reason: Repetitive behaviors in OCD, such as cleaning, are attempts to decrease the anxiety caused by obsessive thoughts.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following actions is appropriate for the nurse to take?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and observes that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

Correct Answer is D

Explanation

A patient who repeats a word or part of a word over and over might be said to have which of the following symptoms?

Which of these would the nurse implement as the priority action for the patient with newly diagnosed septic shock?

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

The nurse is preparing to teach about the long-term complications for patients diagnosed with diabetes. Which finding is accurate?

Which of the following is a role of the LPN in the preoperative phase? Select all that apply.

Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:

During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

Effective coping skills are described as: