OCD
A nurse is assessing a client who reports spending excessive time checking that doors are locked before leaving the house. Which statement by the client best indicates an obsession rather than a compulsion?
A) "I feel an overwhelming urge to check the doors multiple times before I can leave."
B) "I know I checked the doors, but I keep thinking that they might still be unlocked."
C) "I feel relieved for a moment after checking the door, but then the urge comes back."
D) "If I don’t check the doors exactly five times, I fear something bad will happen."
Correct Answer: B – "I know I checked the doors, but I keep thinking that they might still be unlocked."
Rationale: Obsessions are intrusive, unwanted thoughts or fears that cause distress. In this case, the thought that the doors might still be unlocked is an obsession because it is persistent and distressing, even when the client logically knows the doors are locked.
A nurse is assessing a client with major depressive disorder (MDD). Which of the following symptoms would be considered a core feature of depression?
A) Frequent mood swings between euphoria and sadness
B) Recurrent intrusive thoughts and compulsions
C) Loss of interest or pleasure in previously enjoyed activities
D) Increased energy and decreased need for sleep
Correct Answer: C – "Loss of interest or pleasure in previously enjoyed activities."
Rationale: Anhedonia (loss of interest or pleasure in activities) is a hallmark symptom of depression.
A nurse is assessing a client who reports frequent episodes of worry and restlessness but can still complete daily tasks. Which level of anxiety does this describe?
A) Mild
B) Moderate
C) Severe
D) Panic
Correct Answer: A – "Mild."
Mild anxiety is adaptive and may actually enhance problem-solving abilities. The client experiences restlessness but remains functional.
Which of the following neurotransmitters is most associated with the action of antidepressants?
A) Dopamine and Glutamate
B) GABA and Acetylcholine
C) Serotonin and Norepinephrine
D) Endorphins and Histamine
Correct Answer: C – "Serotonin and Norepinephrine."
Rationale: Serotonin (5-HT) and Norepinephrine (NE) are the primary neurotransmitters targeted by antidepressants like SSRIs, SNRIs, and TCAs.
A nurse is assessing a client with anorexia nervosa. Which of the following physical manifestations should the nurse expect?
A) Bradycardia and hypotension
B) Increased body temperature and diaphoresis
C) Hypertension and tachycardia
D) Hyperactive bowel sounds and diarrhea
Correct Answer: A – "Bradycardia and hypotension."
Clients with anorexia nervosa often experience bradycardia, hypotension, hypothermia, and lanugo due to severe malnutrition.
A nurse is assessing a client with somatic symptom disorder (SSD). Which of the following characteristics are most common in this disorder?.
A) Multiple unexplained physical symptoms that cause significant distress
B) Fear of developing a serious illness despite negative medical tests
C) Preoccupation with an imagined defect in appearance
D) Exaggerated concern about having a serious medical illness after reading about it online
Correct Answer: A – "Multiple unexplained physical symptoms that cause significant distress."
Somatic symptom disorder (SSD) is characterized by excessive distress and preoccupation with physical symptoms that lack a medical explanation.
A nurse is using therapeutic communication with a client diagnosed with schizophrenia who is experiencing paranoia. Which of the following statements or actions by the nurse are appropriate? (Select all that apply.)
A) "I understand that you feel unsafe right now. Can you tell me more about what’s making you feel this way?"
B) "There’s nothing to be afraid of. You’re imagining things."
C) Sitting with the client in a non-threatening manner, allowing them space to speak when ready.
D) "Let’s change the subject and talk about something positive instead."
E) "I’m here to support you, and I will stay with you to ensure your safety."
Correct Answers: A, C, E
Rationale:
A nurse is assessing a client with OCD who repeatedly washes their hands until their skin becomes raw. Which primary reason explains why the client engages in this compulsive behavior?
A) To maintain good hygiene and prevent infection
B) To feel pleasure from completing the ritual
C) To temporarily reduce anxiety caused by obsessive thoughts
D) To seek attention from others
Correct Answer: C – "To temporarily reduce anxiety caused by obsessive thoughts."
Rationale: Clients with OCD do not perform compulsions for pleasure or hygiene, but rather to relieve the distress caused by obsessive thought
A client with depression states, "I feel like a failure and that everyone would be better off without me." What is the nurse’s priority action?
A) Encourage the client to focus on positive aspects of their life.
B) Ask the client directly if they are having thoughts of self-harm.
C) Reassure the client that their feelings will improve with treatment.
D) Avoid discussing suicidal thoughts to prevent reinforcing negative thinking.
Correct Answer: B – "Ask the client directly if they are having thoughts of self-harm."
Rationale: Assessing suicide risk is always the priority when a client expresses hopelessness or feelings of worthlessness.
A nurse is assessing a client experiencing moderate anxiety. Which physiological symptom is most likely to be observed?
A) Hyperventilation and inability to speak
B) Trembling, increased heart rate, and muscle tension
C) Hallucinations and delusions
D) Dizziness, numbness, and chest pain
Correct Answer: B – "Trembling, increased heart rate, and muscle tension."
Rationale: Moderate anxiety causes increased sympathetic nervous system activation (e.g., trembling, tachycardia, and muscle tension).
A client is prescribed fluoxetine (Prozac). The nurse should teach the client that full therapeutic effects may take how long?
A) 3-5 days
B) 1-2 weeks
C) 4-6 weeks
D) Immediately
Correct Answer: C – "4-6 weeks."
Rationale: SSRIs like fluoxetine take 4-6 weeks to reach full therapeutic effect due to gradual serotonin receptor adaptation.
A client with bulimia nervosa presents to the clinic for an evaluation. Which of the following findings should the nurse expect?
A) Calloused knuckles and dental erosion
B) Lanugo and amenorrhea
C) Osteoporosis and muscle wasting
D) Hypertension and obesity
Correct Answer: A – "Calloused knuckles and dental erosion."
Calloused knuckles (Russell’s sign) and dental erosion result from frequent self-induced vomiting in bulimia nervosa.
A client with illness anxiety disorder (IAD) tells the nurse, "I know something is seriously wrong with me, but the doctors just aren’t finding it!" Which of the following findings support this diagnosis?
A) The client frequently switches healthcare providers despite repeated negative test results.
B) The client develops unexplained paralysis after experiencing emotional distress.
C) The client exaggerates pain symptoms to obtain opioid prescriptions.
D) The client has episodes of compulsively pulling out their own hair due to stress.
Correct Answer: A – "The client frequently switches healthcare providers despite repeated negative test results."
Rationale:
A client tells the nurse, "I feel like my family would be better off without me." Which therapeutic responses should the nurse use? (Select all that apply.)
A) "Are you thinking about hurting yourself?"
B) "Try to think about the good things in your life instead of these thoughts."
C) "You must be feeling really hopeless right now. I’d like to understand what’s making you feel this way."
D) "Don’t say that, your family loves you and needs you."
E) "Have you thought about how you would hurt yourself?"
Correct Answers: A, C, E
Rationale:
A nurse is providing education to a client newly diagnosed with OCD. The nurse explains that which of the following is considered the first-line treatment for OCD?
A) Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP)
B) Benzodiazepines to quickly reduce compulsive behaviors
C) Electroconvulsive Therapy (ECT) for severe cases
D) Psychoanalysis to uncover early childhood trauma
Answer: Correct Answer: A – "Cognitive Behavioral Therapy (CBT), specifically Exposure and Response Prevention (ERP)."
Rationale: CBT with Exposure and Response Prevention (ERP) is the gold standard treatment for OCD. ERP involves gradual exposure to anxiety-provoking thoughts while preventing compulsive responses, helping the client build tolerance to distress.
A client with depression says, "I don’t think I’ll ever feel happy again. Nothing helps." What is the most therapeutic nursing response?
A) "That’s not true, things will get better soon."
B) "It sounds like you're feeling really hopeless right now."
C) "If you try harder to focus on the good things, you’ll feel better."
D) "You just need to give it time; depression takes a while to go away."
Correct Answer: B – "It sounds like you're feeling really hopeless right now."
Rationale: This response validates the client’s emotions and encourages further communication.
A client with generalized anxiety disorder (GAD) says, "I can't stop worrying about everything. My mind just keeps racing." What is the most therapeutic response by the nurse?
A) "Try not to think about it so much. It’s all in your head."
B) "It sounds like your worries feel overwhelming right now. Let’s talk about what’s bothering you the most."
C) "You should focus on positive thoughts instead of worrying all the time."
D) "That’s normal. Everyone worries about things sometimes."
Correct Answer: B – "It sounds like your worries feel overwhelming right now. Let’s talk about what’s bothering you the most."
Rationale: This response validates the client’s feelings and encourages open discussion, which is a key component of therapeutic communication.
A nurse is monitoring a client taking haloperidol (Haldol). Which of the following extrapyramidal symptoms (EPS) should the nurse watch for?
A) Dry mouth and constipation
B) Involuntary muscle spasms and rigidity
C) Sedation and weight gain
D) Hyperactivity and restlessness
Correct Answer: B – "Involuntary muscle spasms and rigidity."
Rationale: EPS include dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia.
A client with anorexia nervosa is admitted to an inpatient unit for nutritional rehabilitation. Which of the following nursing interventions should be included in the plan of care?
A) Weigh the client daily after meals to prevent purging.
B) Allow the client to select their meals independently to promote autonomy.
C) Monitor the client during and after meals for at least 60 minutes.
D) Encourage the client to eat alone to reduce meal-related anxiety.
Correct Answer: C – "Monitor the client during and after meals for at least 60 minutes."
C is correct because clients with eating disorders may try to hide, discard, or purge food, so close monitoring is necessary.
A nurse is planning care for a client with somatic symptom disorder (SSD). Which of the following interventions should be included?
A) Encourage the client to explore feelings rather than focus on physical symptoms.
B) Provide detailed explanations of why their symptoms are not medically real.
C) Reassure the client that their symptoms will go away with time.
D) Limit discussion of symptoms to discourage reinforcement of somatic complaints.
Correct Answer: A – "Encourage the client to explore feelings rather than focus on physical symptoms."
A is correct because helping the client process underlying emotional distress can reduce somatic symptom expression.
A client with borderline personality disorder (BPD) repeatedly tries to engage the nurse in favoritism and makes excessive personal requests. Which of the following are appropriate nursing responses? (Select all that apply.)
A) "I care about your well-being, but I have to treat all my patients equally."
B) "If you keep acting this way, I won’t be able to work with you anymore."
C) "I understand you’re feeling upset, but I can’t grant that request."
D) "We discussed boundaries earlier. Let’s go over them again to help you feel secure."
E) "I’ll make an exception this time, but try not to ask again."
Correct Answers: A, C, D
Rationale:
A nurse is educating a client with OCD about their new prescription for fluoxetine (Prozac). Which statement by the client indicates a need for further teaching?
A) "It may take a few weeks before I start to notice a difference in my symptoms."
B) "I should stop taking the medication as soon as I feel better to avoid side effects."
C) "This medication is an SSRI that helps reduce obsessive thoughts and compulsive behaviors."
D) "I should take the medication daily, even if I feel fine."
Correct Answer: B – "I should stop taking the medication as soon as I feel better to avoid side effects."
Rationale: SSRIs (Selective Serotonin Reuptake Inhibitors) are the first-line pharmacologic treatment for OCD.
A nurse is educating a client who has been prescribed fluoxetine (Prozac) for depression. Which statement by the client indicates a need for further teaching?
A) "It may take several weeks before I notice an improvement in my mood."
B) "I should avoid stopping this medication suddenly."
C) "I can take St. John’s Wort to help boost the effects of this medication."
D) "I might experience some nausea or headache when I first start taking this."
Correct Answer: C – "I can take St. John’s Wort to help boost the effects of this medication."
Rationale: St. John’s Wort can interact with SSRIs (like fluoxetine) and increase the risk of serotonin syndrome, a potentially life-threatening condition.
A client with panic disorder is prescribed alprazolam (Xanax). Which teaching point should the nurse emphasize?
A) "Take this medication only when you feel an anxiety attack coming on."
B) "This medication may take 2-4 weeks to show full effects."
C) "Avoid alcohol and do not stop this medication suddenly."
D) "This medication will permanently cure your anxiety disorder."
Correct Answer: C – "Avoid alcohol and do not stop this medication suddenly."
Rationale:
Benzodiazepines (like alprazolam) can cause dependence and withdrawal symptoms if stopped abruptly. Alcohol use can increase sedation and respiratory depression.
A client with bipolar disorder is taking lithium (Lithobid). The nurse should instruct the client to:
A) Increase sodium intake to enhance lithium levels
B) Drink plenty of fluids and maintain normal sodium intake
C) Stop lithium immediately if nausea occurs
D) Avoid all dairy products while taking lithium
Correct Answer: B – "Drink plenty of fluids and maintain normal sodium intake."
Rationale: Lithium is a salt, and changes in sodium levels affect its therapeutic range.
A nurse is educating a client with bulimia nervosa about cognitive-behavioral therapy (CBT). Which statement by the client indicates understanding?
A) "I should focus on suppressing all thoughts about food and weight."
B) "If I eat a 'bad' food, I have to compensate by skipping my next meal."
C) "I need to identify and challenge my negative thoughts about food and my body image."
D) "Avoiding all foods that trigger my bingeing is the best way to manage my disorder."
Correct Answer: C – "I need to identify and challenge my negative thoughts about food and my body image."
CBT focuses on identifying and modifying negative thought patterns and behaviors.
A nurse is caring for a client diagnosed with conversion disorder (functional neurological symptom disorder). Which of the following manifestations are characteristic of this disorder?
A) Sudden blindness, paralysis, or seizures without a medical cause
B) Preoccupation with having a serious illness despite negative tests
C) Fear of public places due to panic attacks
D) Intentionally faking symptoms for personal gain
Correct Answer: A – "Sudden blindness, paralysis, or seizures without a medical cause."
Conversion disorder presents as neurological symptoms (e.g., paralysis, blindness, seizures) without a known medical explanation, often triggered by psychological stress.
A client with severe anxiety is pacing, clenching their fists, and breathing rapidly. Which interventions should the nurse use? (Select all that apply.)
A) Speak in a calm, low-pitched voice while using short, simple sentences.
B) Encourage the client to sit down and discuss their feelings.
C) Guide the client through deep breathing exercises.
D) Use firm touch to reassure the client that they are safe.
E) Stay with the client until their anxiety decreases.
Correct Answers: A, C, E
Rationale:
A client with OCD is hospitalized due to extreme distress and an inability to function due to compulsive handwashing. The nurse observes the client scrubbing their hands for over 30 minutes, crying, and appearing highly distressed. What is the nurse’s priority action?
A) Interrupt the compulsion and redirect the client to another activity immediately
B) Allow the client to continue washing to avoid further distress
C) Offer a prescribed SSRI and monitor for improvement
D) Acknowledge the client’s distress and gradually introduce response prevention techniques
Correct Answer: D – "Acknowledge the client’s distress and gradually introduce response prevention techniques."
Rationale: Clients with OCD experience extreme distress when compulsions are interrupted abruptly.
{DOUBLE JEOPARDY}
A client with severe depression and suicidal ideation is admitted to an inpatient psychiatric unit. Which nursing intervention has the highest priority?
A) Encouraging the client to verbalize their feelings
B) Ensuring continuous one-on-one observation
C) Administering PRN sedatives as needed
D) Providing the client with a private room to rest
Correct Answer: B – "Ensuring continuous one-on-one observation."
Rationale: For clients with suicidal ideation, safety is the top priority. One-on-one observation prevents self-harm.
A client with severe anxiety is pacing and clenching their fists, stating, "I can’t take this anymore!" What is the nurse’s priority action?
A) Tell the client to sit down and relax
B) Use a calm tone and encourage deep breathing exercises
C) Challenge the client’s anxious thoughts to help them gain perspective
D) Ask the client why they are feeling anxious
Correct Answer: B – "Use a calm tone and encourage deep breathing exercises."
Rationale: The priority is to lower the client’s immediate distress using grounding techniques.
A client with generalized anxiety disorder (GAD) is prescribed buspirone (Buspar). Which statement by the client indicates a need for further teaching?
A) "This medication may take 2-4 weeks to be effective."
B) "I can take it as needed when I feel anxious."
C) "It does not cause sedation like benzodiazepines."
D) "I should take it consistently every day."
Correct Answer: B – "I can take it as needed when I feel anxious."
Rationale: Buspirone is a non-benzodiazepine anxiolytic that requires daily dosing and takes 2-4 weeks to take effect.
A client with anorexia nervosa is receiving nutritional rehabilitation therapy. The nurse should monitor for which life-threatening complication associated with refeeding?
A) Hyperglycemia and dehydration
B) Hypokalemia and cardiac arrhythmias
C) Increased appetite and rapid weight gain
D) Liver failure and jaundice
Correct Answer: B – "Hypokalemia and cardiac arrhythmias."
Refeeding syndrome occurs when a malnourished client is given nutrition too rapidly, leading to electrolyte imbalances (hypokalemia, hypophosphatemia, hypomagnesemia) and cardiac complications.
A nurse is teaching a group of nursing students about the differences between illness anxiety disorder (IAD) and somatic symptom disorder (SSD). Which of the following *statements are accurate? (Select all that apply.)
A) In IAD, clients have minimal or no physical symptoms but have excessive worry about illness.
B) Clients with SSD experience actual distressing physical symptoms, but medical tests do not explain them.
C) IAD is characterized by deliberate exaggeration of symptoms to seek attention.
D) In SSD, the client’s distress about symptoms is disproportionate to any actual medical findings.
E) IAD and SSD are both treated with cognitive-behavioral therapy (CBT) as a first-line approach.
Correct Answers: A, B, D, E
A client states, "The voices keep telling me I'm worthless." Which nursing responses are appropriate? (Select all that apply.)
A) "I understand that you hear voices, but I do not hear them."
B) "What are the voices telling you to do?"
C) "The voices aren’t real. You need to try to ignore them."
D) "I know these voices seem real to you. Tell me how you're feeling about what they’re saying."
E) "I want to help you, but I need to know if the voices are telling you to hurt yourself or others."
Correct Answers: A, B, D, E
Rationale:
A client with OCD is preparing for discharge and states, "I feel like my rituals are better, but I’m worried I’ll never be completely cured." How should the nurse respond?
A) "You shouldn’t think that way; OCD is very treatable."
B) "OCD is a chronic condition, but you can learn to manage your symptoms effectively."
C) "You should be positive! Thinking negatively can make OCD worse."
D) "You’ll be cured soon as long as you keep taking your medication."
Correct Answer: B – "OCD is a chronic condition, but you can learn to manage your symptoms effectively."
Rationale: OCD is a chronic condition, but with proper treatment, individuals can manage symptoms effectively and lead functional lives.
A client receiving CBT for depression is learning to identify and challenge negative thought patterns. Which client statement best reflects cognitive restructuring?
A) "I always fail at everything, so there’s no point in trying."
B) "Maybe I didn’t do well this time, but that doesn’t mean I’ll always fail."
C) "If I just ignore my negative thoughts, they will go away on their own."
D) "My depression will never get better, no matter what I do."
Correct Answer: B – "Maybe I didn’t do well this time, but that doesn’t mean I’ll always fail."
Rationale: Cognitive restructuring helps clients challenge distorted thoughts and replace them with more balanced perspectives.
A nurse is teaching a client with social anxiety disorder (SAD) about cognitive reframing, a key component of CBT. Which client statement best demonstrates understanding?
A) "I’ll just avoid social situations so I don’t feel anxious."
B) "I’ll remind myself that people probably aren’t judging me as much as I think they are."
C) "I should force myself into social situations until I no longer feel anxious."
D) "If I start to feel anxious, I’ll take a deep breath and leave immediately."
Correct Answer: B – "I’ll remind myself that people probably aren’t judging me as much as I think they are."
Rationale: Cognitive reframing involves challenging irrational thoughts and replacing them with more balanced, realistic ones. .
A nurse is caring for a client who started venlafaxine (Effexor), an SNRI, 3 days ago. The client reports agitation, sweating, tachycardia, and muscle rigidity. What is the nurse’s priority action?
A) Administer a PRN benzodiazepine to reduce symptoms
B) Reassure the client that these symptoms are temporary
C) Discontinue venlafaxine and notify the provider immediately
D) Encourage the client to drink fluids and rest
Correct Answer: C – "Discontinue venlafaxine and notify the provider immediately."
Rationale: These symptoms suggest serotonin syndrome, a medical emergency caused by excessive serotonin levels.
A nurse is educating the family of a teenager with anorexia nervosa about Family-Based Treatment (FBT). Which of the following statements should the nurse include?
A) "Your child will need to take full responsibility for their eating habits as part of treatment."
B) "Your family will play a central role in helping your child regain weight and normalize eating behaviors."
C) "FBT is less effective than inpatient treatment and should only be used as a last resort."
D) "It’s best for your child to recover independently to regain control over their eating habits."
Correct Answer: B – "Your family will play a central role in helping your child regain weight and normalize eating behaviors."
Rationale:
A nurse is evaluating a client suspected of factitious disorder imposed on self. Which of the following behaviors support this diagnosis?
A) The client induces illness in themselves to assume the "sick role."
B) The client reports chronic pain in multiple body parts but avoids seeking treatment.
C) The client fabricates symptoms to obtain a financial settlement.
D) The client develops paralysis after a traumatic event but shows no distress about it.
Correct Answer: A – "The client induces illness in themselves to assume the 'sick role.'"
Rationale:
A client in a psychiatric unit is becoming verbally aggressive and yelling at staff. Which interventions should the nurse implement first? (Select all that apply.)
A) Maintain a calm and non-threatening demeanor.
B) Stand directly in front of the client to establish authority.
C) Set clear, simple limits on the behavior.
D) Move other clients away from the area.
E) Call security immediately and restrain the client.
Correct Answers: A, C, D
Rationale:
A client with treatment-resistant OCD has not responded to multiple SSRIs and ERP therapy. Which next-step treatment would a psychiatrist likely consider?
A) Deep brain stimulation (DBS)
B) Increased exposure therapy without medication
C) Adding a stimulant medication to improve focus
D) Discontinuing treatment and trying meditation alone
Correct Answer: A – "Deep brain stimulation (DBS)."
Rationale: DBS is an emerging treatment for severe, treatment-resistant OCD.
A client with treatment-resistant depression has not responded to multiple SSRIs and CBT. Which next-step treatment is most appropriate?
A) Electroconvulsive Therapy (ECT)
B) Increasing SSRI dosage beyond the recommended limit
C) Switching to a stimulant medication like Adderall
D) Stopping all medications and relying solely on psychotherapy
Answer: Correct Answer: A – "Electroconvulsive Therapy (ECT)."
Rationale: ECT is used for severe, treatment-resistant depression, especially if the client has suicidal ideation or psychotic features.
A client with severe generalized anxiety disorder (GAD) has tried multiple SSRIs with minimal improvement. Which next-step treatment is most appropriate?
A) Buspirone (Buspar), a non-benzodiazepine anxiolytic
B) A stimulant medication, such as methylphenidate
C) Deep brain stimulation (DBS)
D) Electroconvulsive therapy (ECT) as the first-line treatment
Correct Answer: A – "Buspirone (Buspar), a non-benzodiazepine anxiolytic."
Rationale: Buspirone is a non-sedating anxiolytic that is effective for long-term management of GAD without the risk of dependence.
A client taking phenelzine (Nardil), an MAOI, asks about dietary restrictions. The nurse should instruct the client to avoid which food?
A) Grilled chicken
B) Cheddar cheese
C) Whole grain bread
D) Boiled eggs
Correct Answer: B – "Cheddar cheese."
Rationale: MAOIs require a strict diet to prevent hypertensive crisis caused by tyramine-rich foods.
A client with binge-eating disorder (BED) asks about medications that can help manage their condition. The nurse should educate the client about which FDA-approved medication for BED?
A) Fluoxetine (Prozac)
B) Bupropion (Wellbutrin)
C) Lisdexamfetamine (Vyvanse)
D) Risperidone (Risperdal)
Correct Answer: C – "Lisdexamfetamine (Vyvanse)."
Lisdexamfetamine (Vyvanse) is the only FDA-approved medication specifically for BED and helps reduce binge episodes.
A nurse is providing discharge teaching for a client diagnosed with somatic symptom disorder (SSD). Which of the following statements should be included in the teaching?
A) "We will focus on managing your stress and emotional health rather than eliminating your symptoms entirely."
B) "Once you accept that your symptoms are psychological, they will go away completely."
C) "Avoid discussing your physical symptoms during therapy, as it can reinforce the disorder."
D) "Taking anti-anxiety medication will cure your symptoms."
Correct Answer: A – "We will focus on managing your stress and emotional health rather than eliminating your symptoms entirely."
Rationale:
A client with post-traumatic stress disorder (PTSD) is experiencing a flashback and is visibly distressed. Which nursing interventions are appropriate? (Select all that apply.)
A) Orient the client to the present by stating the date and location.
B) Encourage the client to describe the traumatic event in detail.
C) Use grounding techniques, such as asking the client to feel their feet on the floor.
D) Speak in a calm, reassuring voice and provide emotional support.
E) Avoid touching the client unless given permission.
Correct Answers: A, C, D, E
Rationale: