A nurse in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit.
Which of the following actions should the mental health nurse plan to take regarding the client's compulsive behaviors?
Plan the client's schedule to allow time for rituals.
Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
Confront the client about the senseless nature of the repetitive behaviors.
Isolate the client for a period of time.
The Correct Answer is A
Choice A rationale:
1. Understanding OCD:
OCD is a chronic mental health condition characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions).
Individuals with OCD feel compelled to perform rituals to relieve anxiety or prevent perceived harm, even if they recognize the behaviors as excessive or irrational.
Rituals can consume significant time and interfere with daily functioning.
2. Rationale for Choice A:
Acknowledges the client's needs: Planning for rituals demonstrates understanding and acceptance of the client's experience, fostering trust and rapport.
Reduces anxiety: Allowing time for rituals can temporarily reduce anxiety, making the client more receptive to other interventions.
Gradual approach: It's a stepping stone towards Exposure and Response Prevention (ERP), the gold-standard treatment for OCD.
Enhances control: Scheduling rituals can help the client feel more in control, reducing the urge to engage in them compulsively.
3. Addressing potential concerns:
Reinforcing rituals: While there's a possibility of temporarily reinforcing rituals, it's a necessary first step to build trust and engagement in therapy.
Interfering with treatment: Scheduling rituals is a part of a comprehensive treatment plan that includes ERP and other therapies to address the underlying causes of OCD.
4. Importance of individualized care:
The specific approach to planning for rituals should be tailored to the client's unique needs, preferences, and severity of symptoms.
Collaboration with the client is essential to ensure their active participation in treatment. I'll now address the rationales for the incorrect choices:
Choice B rationale:
Setting strict limits on behaviors can be counterproductive: Triggers anxiety and distress
Impedes trust and therapeutic alliance Diminishes sense of control
Heightens resistance to treatment
Choice C rationale:
Confronting the client about the senselessness of rituals is ineffective and potentially harmful: Exacerbates anxiety and shame
Alienates the client
Disregards the involuntary nature of OCD Undermines motivation for treatment Choice D rationale:
Isolating the client is unethical and detrimental:
Increases distress and loneliness Impedes therapeutic interactions Reinforces negative self-perceptions
Lacks evidence of efficacy in OCD treatment
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
The nurse should administer 2 tablets per dose.
Rationale:
Step 1: Determine the desired dose of diphenhydramine. The desired dose is 50 mg.
Step 2: Determine the available tablet strength. The available tablet strength is 25 mg.
Step 3: Divide the desired dose by the tablet strength to determine the number of tablets needed. 50 mg / 25 mg/tablet = 2 tablets
Therefore, the nurse should administer 2 tablets of diphenhydramine 25 mg per dose to achieve the desired dose of 50 mg.
Correct Answer is C
Explanation
Choice A rationale:
This response indicates anger, not denial. The client is expressing anger towards the doctor and their perceived lack of competence. While anger can be a component of the grief process, it does not specifically align with the denial phase, which is characterized by a refusal to accept the reality of a situation.
Choice B rationale:
This response indicates fatigue or depression, not denial. The client is acknowledging their physical and emotional state but is not expressing disbelief or refusal to accept their diagnosis.
Choice C rationale:
This response clearly demonstrates denial. The client is minimizing the severity of their diagnosis and attributing the doctor's statements to an ulterior motive. This is a classic example of denial, as it involves a distortion of reality to avoid facing a painful truth.
Choice D rationale:
This response indicates acceptance, not denial. The client is acknowledging the reality of their situation and expressing gratitude for the care they have received.
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