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 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

3. A female client with severe depression who has been on antidepressants for two weeks suddenly becomes more energetic and talkative. What action should the RN take first?

Correct answer: B

Rationale: A sudden increase in energy and talkativeness in a client with severe depression who has been on antidepressants for a short period may indicate an increased risk of suicide due to the potential shift from profound sadness to motivation to act. The first action the RN should take is to monitor the client closely for signs of suicidal behavior. Encouraging participation in group activities or praising the client for the apparent improvement may overlook the potential risk of suicidal behavior. While discussing the client's progress with the healthcare provider is important, the immediate concern is to ensure the client's safety by closely monitoring for any signs of suicidal ideation or behavior.

4. A nurse is providing discharge teaching to a client with schizophrenia who is prescribed clozapine (Clozaril). Which information should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'You need to come in for regular blood tests.' Clozapine can cause agranulocytosis, a potentially life-threatening condition, so regular blood tests are required to monitor the client's white blood cell count. Choice B is incorrect because clozapine is associated with weight gain, not weight loss. Choice C is incorrect because the client should never stop taking clozapine abruptly due to the risk of withdrawal symptoms and symptom relapse. Choice D is incorrect because avoiding foods high in tyramine is typically associated with MAOIs, not clozapine.

5. A client with PTSD is experiencing flashbacks and nightmares. Which intervention should the nurse implement first?

Correct answer: A

Rationale: Encouraging the client to talk about the flashbacks is the most appropriate initial intervention for a client with PTSD experiencing flashbacks and nightmares. This intervention helps the client express their feelings, thoughts, and experiences related to the trauma they are going through. It can assist in processing the traumatic events and starting the healing process. Choice B, assisting the client in developing coping strategies, is important but should come after the client has started to verbalize and process their experiences. Choice C, discussing relaxation techniques, may be beneficial later in the treatment process but may not be as effective initially as addressing the traumatic experiences. Choice D, referring the client to a PTSD support group, is also valuable but may not be as immediate as encouraging the client to talk about their flashbacks to begin the therapeutic process.

Similar Questions

A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?
A female client with bulimia nervosa is admitted to the hospital. Which intervention should the nurse include in the plan of care?
The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance abuse places the client at the highest risk for myocardial infarction?
Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?
A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?

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