a patient with obsessive compulsive disorder ocd performs hand washing repeatedly which nursing intervention is most appropriate
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Nursing Elites

ATI LPN

ATI Mental Health Practice A 2023

1. A patient with obsessive-compulsive disorder (OCD) performs hand washing repeatedly. Which nursing intervention is most appropriate?

Correct answer: C

Rationale: Allowing the patient to wash hands at specified times is the most appropriate nursing intervention for a patient with OCD who repetitively performs hand washing. This intervention provides structure by allowing the patient to engage in the behavior at designated times, helping to reduce the compulsion gradually. Restricting or setting strict limits may increase anxiety and worsen the condition, while ignoring the behavior does not address the underlying issue of OCD.

2. Which individual is likely experiencing symptoms of derealization?

Correct answer: A

Rationale: The individual describing feeling like they are looking at life through a fog and questioning their reflection in the mirror is likely experiencing symptoms of derealization. Derealization involves feelings of detachment from one's surroundings, which can manifest as a sense of unreality or distortion of the environment. Choice B describes dissociative amnesia, which involves memory loss related to personal information or traumatic events. Choice C suggests dissociative identity disorder (DID), where a person experiences two or more distinct identities or personality states. Choice D indicates symptoms of a panic attack, such as fearing imminent death and physical sensations like a heart attack.

3. What assessment question will provide insight into the effects of a woman’s circadian rhythms on her quality of life?

Correct answer: A

Rationale: Inquiring about the amount of sleep a woman gets each night is crucial in understanding how her circadian rhythms may be affecting her quality of life. Circadian rhythms play a significant role in regulating sleep-wake cycles, and disruptions in these rhythms can impact overall well-being and quality of life.

4. A healthcare professional is assessing a patient with major depressive disorder. Which finding is most concerning?

Correct answer: C

Rationale: Among the symptoms listed, difficulty sleeping is particularly concerning in patients with major depressive disorder. Insomnia or other sleep disturbances can exacerbate depressive symptoms and increase the risk of suicidal ideation. Healthcare professionals should address sleep issues promptly to provide appropriate interventions and prevent further complications.

5. What assessment findings would indicate lithium toxicity in a patient hospitalized for an acute manic episode?

Correct answer: B

Rationale: In a patient suspected of lithium toxicity, the presence of ataxia, severe hypotension, and a large volume of dilute urine are key assessment findings. Ataxia is a sign of central nervous system involvement, severe hypotension indicates cardiovascular effects, and a large volume of dilute urine suggests renal impairment, all of which are commonly seen in severe lithium toxicity. Options A, C, and D do not align with typical signs of lithium toxicity.

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