a client with obsessive compulsive disorder ocd repeatedly washes her hands throughout the day what is the most therapeutic nursing intervention
Logo

Nursing Elites

HESI LPN

HESI Mental Health 2023

1. A client with obsessive-compulsive disorder (OCD) repeatedly washes her hands throughout the day. What is the most therapeutic nursing intervention?

Correct answer: B

Rationale: Encouraging the client to talk about the underlying fears is the most therapeutic nursing intervention for a client with OCD who repeatedly washes her hands. By discussing the fears, the client can gain insight into the behavior and work towards reducing the compulsion. Choice A is incorrect as allowing the client to continue the behavior can perpetuate the OCD symptoms. Choice C is incorrect as restricting access to soap and water can lead to increased anxiety and distress. Choice D is incorrect as scheduling a time for the client to perform the ritual does not address the underlying fears driving the behavior.

2. A female client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. What is the priority nursing intervention?

Correct answer: D

Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.

3. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

4. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

5. What is the priority intervention for a client with major depressive disorder admitted to the psychiatric unit with suicidal ideation?

Correct answer: A

Rationale: The correct answer is to conduct a thorough suicide risk assessment. When a client with major depressive disorder presents with suicidal ideation, the priority is to assess the level of risk to ensure the client's safety. This assessment helps determine the appropriate interventions, level of care, and monitoring needed. Encouraging the client to verbalize their feelings (choice B) is important, but not the priority when immediate safety is a concern. Providing positive affirmations (choice C) and referring the client to group therapy (choice D) may be beneficial interventions later on but do not address the immediate risk of harm to the client.

Similar Questions

A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?
A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?
A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, 'I won't leave my son! Don't you touch him! You'll hurt my child!' What is the best interpretation of the mother's statements? The mother is

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses