a client with obsessive compulsive disorder ocd spends several hours each day washing her hands which intervention should the nurse implement
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Nursing Elites

ATI RN

ATI Mental Health Proctored Exam 2019

1. A client with obsessive-compulsive disorder (OCD) spends several hours each day washing her hands. Which intervention should the nurse implement?

Correct answer: B

Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.

2. Which response demonstrates accurate information that should be discussed with the female patient diagnosed with bipolar disorder and her support system? Select the incorrect one.

Correct answer: B

Rationale: In managing bipolar disorder, it is vital to educate the patient and their support system about triggers like alcohol and caffeine, the significance of good sleep, and the need for family involvement. However, the statement in choice B is incorrect. While antidepressants need to be carefully monitored in bipolar disorder, they can be used in conjunction with mood stabilizers to manage depression in some cases.

3. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?

Correct answer: A

Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia. Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.

4. Which symptom should a healthcare provider identify as typical of the fight-or-flight response?

Correct answer: B

Rationale: The correct answer is B: Increased heart rate. During the fight-or-flight response, the sympathetic nervous system is activated, causing the release of epinephrine. This hormone triggers an increase in heart rate to supply more blood to the muscles for a rapid response. Pupil dilation occurs to enhance vision in preparation for quick reactions. On the other hand, salivation and peristalsis decrease as the body prioritizes functions necessary for immediate action rather than digestion-related activities. Therefore, choices A, C, and D are incorrect as they do not align with the typical physiological changes associated with the fight-or-flight response.

5. A healthcare professional is assessing a client diagnosed with body dysmorphic disorder. Which of the following findings should the healthcare professional expect?

Correct answer: A

Rationale: The correct answer is A: Preoccupation with a perceived physical defect. Individuals with body dysmorphic disorder exhibit an obsessive preoccupation with a perceived flaw in their physical appearance, which is often minor or not noticeable to others. This preoccupation causes distress and leads to repetitive behaviors like mirror checking or seeking reassurance about their appearance. Choices B, C, and D are incorrect because fear of gaining weight is more characteristic of an eating disorder, excessive worry about physical symptoms may be seen in somatic symptom disorder, and persistent depressive mood aligns more with depressive disorders rather than body dysmorphic disorder.

Similar Questions

A patient with major depressive disorder is started on a tricyclic antidepressant (TCA). Which common side effect should the nurse educate the patient about?
A healthcare provider is providing care for a patient with schizophrenia. Which symptom would be considered a positive symptom of this disorder?
Which client statement indicates an understanding of the education provided about the antidepressant medication sertraline (Zoloft)?
A client is diagnosed with obsessive-compulsive disorder (OCD), and a nurse is planning care. Which of the following interventions should the nurse exclude from the care plan?
During a manic episode in bipolar disorder, which intervention is most appropriate for a patient?

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