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. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

Correct answer: A

Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.

3. Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

Correct answer: B

Rationale: Checking for congruence between verbal and nonverbal communication helps validate the patient's response.

4. Which characteristic presents the greatest risk for injury to others in a patient diagnosed with schizophrenia?

Correct answer: D

Rationale: Paranoia in patients with schizophrenia can lead to aggressive behaviors, including violence, which poses a significant risk of injury to others. Individuals experiencing paranoia may perceive others as threats and act defensively or aggressively in response, increasing the likelihood of harm to those around them.

5. A patient is being educated about the difference between mental health and mental illness. Which statement by the patient reflects an accurate understanding of mental health?

Correct answer: B

Rationale: The correct answer is B. Mental health is defined as the successful adaptation to stressors in the internal and external environment. This includes having thoughts, feelings, and behaviors that are age-appropriate and congruent with cultural and societal norms. Mental health is not solely the absence of stressors or incongruence between thoughts, feelings, and behavior, nor is it a specific diagnostic category in the DSM-5. Choice A is incorrect because mental health is not just the absence of stressors but the ability to adapt to them. Choice C is wrong as mental health involves congruence, not incongruence, between thoughts, feelings, and behaviors. Choice D is inaccurate as mental health is a broader concept than a specific diagnostic category in the DSM-5.

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