The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? (Select all that apply.)
Refrain from judgmental comments about counting magazines.
Teach the client how to use the technique of thought stopping.
Assist the client to identify circumstances that increase anxiety.
Remove magazines from the commons room when the client attends a group activity.
Correct Answer : A,B,C
Choice A reason: Avoiding judgmental remarks supports therapeutic rapport and prevents worsening anxiety or defensiveness.
Choice B reason: Teaching coping strategies like thought stopping helps the client begin to manage obsessive behaviors more effectively.
Choice C reason: Identifying triggers for obsessive behaviors allows the nurse and client to develop strategies for prevention and management.
Choice D reason: Removing magazines to prevent counting avoids addressing the underlying compulsion and may increase anxiety. This approach is not appropriate in the initial care plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Long-term memory and emotional responses are primarily associated with the limbic system, particularly the hippocampus and amygdala, not the hypothalamus.
Choice B reason: Voluntary muscle control and reflexes are coordinated by the motor cortex and spinal cord, not the hypothalamus.
Choice C reason: Processing sensory input and initiating motor responses are functions of the thalamus and cerebral cortex. The hypothalamus is not directly responsible for this role.
Choice D reason: The hypothalamus regulates homeostasis, including body temperature, thirst, fluid balance, circadian rhythms, and hormone release. A tumor compressing this area explains the patient’s symptoms.
Correct Answer is D
Explanation
Choice A reason: This describes tactile hallucinations, a false sensory experience, not a delusion of reference.
Choice B reason: This reflects a persecutory delusion, where the client believes they are being harmed or targeted, not a delusion of reference.
Choice C reason: This illustrates an auditory hallucination with command-type voices, not a delusion of reference.
Choice D reason: Believing that unrelated environmental cues (like a song) carry special, hidden meaning specifically for the client is the hallmark of a delusion of reference.
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