A psychiatric nurse assesses a client who commonly experiences anxiety. Which comment by this person indicates the possibility of obsessive-compulsive disorder (OCD)?
Select one:
l keep reliving a car accident."
My legs often feel weak and spastic."
I am embarrassed to go out and speak in public."
l check where my car keys are eight times."
The Correct Answer is D
This comment indicates the possibility of obsessive-compulsive disorder (OCD) because it describes a repetitive behavior that may be a compulsion. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. In this case, the individual’s compulsion may be to repeatedly check the location of their car keys in order to reduce anxiety or distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Diarrhea, vomiting, and drowsiness are potential signs of lithium toxicity, which can be a serious and potentially life-threatening condition. If a client who is being treated with lithium carbonate develops these symptoms, the nurse should notify the health care provider immediately and hold the next dose of medication until new orders are received from the provider.
Option a. Hold the medication and refuse to administer additional doses for 3 days is not an appropriate action because it does not involve notifying the health care provider or obtaining new orders.
Option b. Notify the health care provider immediately and give 4 liters of fluids is not an appropriate action because it involves administering fluids without obtaining orders from the health care provider.
Option d. Document the client’s symptoms and continue with medication as prescribed is not an appropriate action because it does not involve notifying the health care provider or holding the next dose of medication.
Correct Answer is D
Explanation
This client is experiencing auditory hallucinations and may be at risk for self-harm or suicide. The nurse should prioritize visiting this client first to assess their safety and provide appropriate interventions.
Option a. A client who recently burned her arm by accident while using a hot iron at home may require wound care and education on safety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option b. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview may benefit from interventions to manage anxiety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option c. A client who requests that her antipsychotic medication be changed due to some new adverse effects may require medication adjustment and monitoring for side effects, but this situation is not as urgent as the client experiencing auditory hallucinations.
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