The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?
Encourage the client to be calm and relax for a little while.
Teach the client thought stopping techniques and ways to refocus behaviors.
Assist the client to identify stimuli that precipitates the activity.
Allow time for the behavior and then redirect the client to other
The Correct Answer is D
A. Simply encouraging the client to be calm and relax may not be effective for someone with obsessive-compulsive disorder.
B.
Teaching techniques is more appropriate for structured therapy sessions rather than addressing compulsive behavior in the moment.
C. While identifying stimuli can be useful, it is not an immediate intervention.
D.
This approach respects the client’s need to complete the compulsion to reduce anxiety while gradually redirecting attention, minimizing distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Providing pain medication to increase the client's tolerance of labor pains: Pain management is important throughout labor, but in the second stage, the focus shifts to pushing efforts and fetal expulsion. Pain medication may affect the client's ability to push effectively and may not be
indicated at this stage.
B. Assessing the fetal heart rate and pattern for signs of fetal distress: Fetal monitoring is essential throughout labor, including the second stage, to assess fetal well-being and detect signs of
distress. However, the specific intervention indicated for the second stage is assisting the client with pushing.
C. Assisting the client to push effectively so that expulsion of the fetus can be achieveD Correct!
In the second stage of labor, the cervix is fully dilated, and the focus is on pushing efforts to
facilitate the birth of the baby. The nurse plays a crucial role in supporting the client during this stage by providing guidance on effective pushing techniques and encouragement.
D. Monitoring effects of oxytocin administration to help achieve cervical dilation: Oxytocin administration is typically used in the first stage of labor to induce or augment contractions and facilitate cervical dilation. Monitoring its effects is important, but it is not a specific intervention for the second stage of labor, where the focus is on pushing and fetal expulsion.
Correct Answer is D
Explanation
A. Client's healthcare power of attorney - This is important legal information but not the most immediate concern for the healthcare provider.
B. Currently prescribed medications - While important, this information does not represent an immediate change in the client's condition.
C. Fall at home as reason for admission - This is background information and, although important, is not the most pressing issue if the client's condition is worsening.
D. Increasing confusion of the client - The increasing confusion could indicate a change in the client's baseline mental status, which could be a sign of a serious condition such as a subdural hematoma or infection and should be communicated immediately.
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