Chapter 15: OCD & Related Disorders
A nurse is visiting a client in the home setting after discharge from the hospital for treatment of multiple area skin infection and cellulitis. Which behavior does the nurse document as a sign that the client is hoarding?
A. A collection of magazines scattered in the living room
B. A single path throughout the yard and house
C. A untidy house and yard
D. A complaint from the neighbors about the cat
Answer: B
Rationale: Hoarding involves excessive acquisition of animals or apparently useless things, cluttered living spaces that become uninhabitable, and significant distress or impairment for the individual. Hoarding can seriously compromise the person's quality of life and even become a health, safety, or public health hazard. Having collectible items does not make the client a hoarder until it becomes excessive. A clear sign of hoarding is a single path to maneuver to and in the home, as clutter builds. It is not uncommon to see an untidy house or yard in any area due to work, illness, or schedules. A complaint from the neighbor about one cat is not significant.
A nurse has been assigned a newly admitted client who demonstrates grandiosity during the assessment by the nurse. Which statement by the client is most consistent with this symptom?
A. "I can understand why my spouse is upset that I overspend."
B. "I can't do anything anymore."
C. "I'm the world's most astute financier."
D. "I can't understand where all the money in our family goes."
Answer: C
Rationale: Grandiose delusions are characterized by the client's claim to association with famous people or celebrities, or the client's belief that they are famous or capable of great feats. For example, the client may claim to be engaged to a famous movie star or related to a public figure. An individual who is demonstrating grandiosity has an exaggerated view of their abilities. The other options are more moderate statements and lack the element of exaggeration.
A client is prescribed sertraline for the treatment of depression. Which outcome would be appropriate to determine an early favorable response to antidepressant medication?
A. The client will establish a balance of rest, sleep, and activity.
B. The client will demonstrate assertive communication skills.
C. The client will describe signs and symptoms of major depression.
D. The client will make plans to attend one community social activity a week.
Answer: A
Rationale: Ability to balance rest, sleep, and activity demonstrates improvement in major depression. Understanding the disorder may occur later when client cognition has improved enough to be able to process information. Initiation of community social activity occurs when the client has increased energy. Assertive communication is learned and practiced after the depression lifts.
A client with antisocial personality disorder starts yelling at another client and calling the client insulting names. Which is the most appropriate response by the nurse?
A. "How would you feel if someone yelled at you like that?"
B. "What's the matter with you? Don't you know any better?"
C. "Yelling at others is unacceptable. You need to let staff know you're upset."
D. "You're still having problems controlling your anger."
Answer: C
Rationale: The nurse must show acceptance of clients as worthwhile persons even if their behavior is unacceptable and set limits for behavior. This means that the nurse must be matter of fact about setting limits and must not make judgmental statements about clients. The nurse must focus only on the behavior.
A nurse is working with the family of a client with obsessive–compulsive disorder (OCD). Which concept will the nurse incorporate in the education plan?
A. The compulsions and obsessions are voluntary and can be eliminated.
B. The thoughts, images, and impulses tend to worsen with stress.
C. The family should pay immediate attention to all symptoms observed.
D. It is likely the client the OCD will not respond to treatment measures.
Answer: B
Rationale: Stress is known to increase the intensity of OCD symptoms. Families should be taught this relationship and the need to reduce stress in the client's life as much as possible. The symptoms are not under the client's voluntary control and may take medication and cognitive–behavioral therapy to obtain a modicum of control over time. It is nontherapeutic to immediately focus on the symptoms, since to do so contributes to secondary gain. OCD responds well to medication and therapy for some clients.
The client with schizophrenia behaves as though the nurse is not trustworthy or that the nurse is questioning their integrity. Which assumption will the nurse make when interacting with this client?
A. The client is correct, and the nurse lacks trustworthy behavior.
B. The client is deliberately attempting to manipulate the nurse.
C. The client's behavior is a part of the disorder and should not be taken personally.
D. The nurse's actions have failed to improve the client’s disorder through treatment.
Answer: C
Rationale: Suspicious or paranoid behavior on the client's part may make the nurse feel as though they are not trustworthy or that their integrity is being questioned. The nurse must recognize this type of behavior as part of the illness and not interpret or respond to it as a personal affront. The nurse must not take responsibility for the success or failure of treatment efforts or view the client's status as a personal success or failure.
A client with bipolar disorder takes lithium 300 mg 3 times daily. The nurse is educating the client on its use, side effects, and need for compliance. Which outcome does the nurse evaluate that indicates the dose is having the beneficial response for the client?
A. Feels sleepy and less energetic
B. Weight gain of 7 pounds in the last 6 months
C. Minimal mood swings
D. Increased feelings of self-worth
Answer: C
Rationale: Mood-stabilizing drugs are used to treat bipolar disorder by stabilizing the client's mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Weight gain is a common side effect, and fatigue and lethargy may indicate mild toxicity. Inflated self-worth is a target symptom of bipolar disorder, which should diminish with effective treatment.
A client with obsessive–compulsive personality disorder says to the nurse, “No one wants to work with me anymore since I have been a supervisor. They say I don’t let anyone else do the work because I don’t trust them.” Which can the nurse do to encourage the client to improve relationships with others at work?
A. Inform the client that it is hard to repair work relationships once impaired.
B. Encourage the client to step down from a supervisory role to see how it feels to be managed.
C. Assist the client to view decision-making and completion of projects from a different perspective.
D. Inform the client they should have a meeting and inform the workers if things were done well, there would be no dissension.
Answer: C
Rationale: The client should be encouraged to look at decision-making and project completion from a different perspective such as accepting that some work may be less than the perfection the client is seeking. With help, relationships in the workplace can be repaired. Making changes can be a positive influence in the workplace. The client should not step down from the supervisory role, since these perceptions will continue into any other role. The client’s authoritarian management style may benefit from cognitive restructuring techniques.
An older adult client without a history of obsessive–compulsive disorder (OCD) is beginning to exhibit compulsions and obsessions. Which action by the nurse is a priority?
A. Educate the client regarding the medications that will be prescribed by the health care provider.
B. Assist with the monitoring of diagnostic testing to rule out an organic cause.
C. Inform the client that these behaviors are indicative of OCD and not caused by other factors.
D. Obtain a 24-hour food recall from the client to determine if the symptoms are food allergies.
Answer: B
Rationale: Recently acquired obsessive or compulsive behavior by an older adult should alert the health care provider to a possible organic cause for the behavior, such as infections, degenerative disorders, brain injury, and cerebrovascular lesions, particularly in the frontal lobes and basal ganglia. Treatment then is directed at the underlying cause, and the obsessive–compulsive behaviors can improve if the underlying cause can be successfully resolved. The nurse’s priority is to assist with determining the underlying cause by monitoring lab studies, diagnostic testing, and clinical manifestations. Medication education is not the priority in this situation since the underlying cause must be identified. The symptoms may not be a true OCD. A 24-hour food recall is not a priority and the symptoms are not likely not in relation to a food allergy.
The nurse is preparing to administer thiothixene to a client with schizophrenia and assesses muscle rigidity, a temperature of 103°F (39.4°C), an elevated serum creatinine phosphokinase level, stupor, and urinary incontinence. Which is the priority action by the nurse?
A. Administer diphenhydramine IM.
B. Administer the medication and notify the health care provider.
C. Hold the medication and notify the health care provider.
D. Administer benztropine IM.
Answer: C
Rationale: The client demonstrates all the classic signs of neuroleptic malignant syndrome (NMS). The medication should not be administered, and the provider should immediately be notified. This can be a fatal reaction to the antipsychotic medication. Any of the antipsychotic medications can cause NMS, which is treated by stopping the medication. The client’s ability to tolerate other antipsychotic medications after NMS varies, but the use of another antipsychotic appears possible in most instances. Diphenhydramine and benztropine are administered for the treatment of dystonia but will not be effective for NMS.
The client has been diagnosed with severe depression and prescribed sertraline. Which assessment of the client by the nurse is a priority after initiation of the medication?
A. Decreased mobility
B. Emotional changes
C. Suicidal ideations
D. Increased sleep
Answer: C
Rationale: Suicide is always a primary consideration when treating clients with depression. The client may begin to feel better and be able to create a plan for harm to self and follow through. Although the other assessments are a priority but not as high as suicide.
The nurse is talking with a client that is suspected of having an avoidant personality disorder. Which behaviors observed by the nurse correlate with this suspicion?
A. Discusses they have three failed marriages but they were not the client’s fault.
B. Cries and has a temper tantrum in the unit whenever requests are denied.
C. Does not speak out in group therapy because fears criticism from others.
D. Shows no remorse when accidentally breaking another client's bracelet.
Answer: C
Rationale: Symptoms suggesting an avoidant personality disorder include fear of rejection, avoidance of relationships, and censorship of expression of thoughts and feelings because of fear of a negative reaction. Borderline personality disorder presents with unstable interpersonal relationships, labile affect, and reports of emptiness. Clients with histrionic personality disorder are overly dramatic, manipulative, and attention-seeking. Clients with schizoid personality disorder are indifferent to and lack concern for interpersonal contacts.
The nurse is educating a client and family member regarding obsessive–compulsive disorder (OCD). Which is essential for the nurse to communicate to the client and to the client's family to promote management of the disorder?
A. The client's diagnosis should be kept from everyone outside the immediate family and friends.
B. The importance of medication adherence and that it may be necessary for medication to be changed to find the one that works best.
C. It is important for the client to avoid following a specific routine to prevent increasing anxiety.
D. It is helpful for others to give advice about other activities the client with OCD can engage in.
Answer: B
Rationale: Teaching about the importance of medication compliance to combat OCD is essential. It is neither possible nor desirable to keep the client's diagnosis from others since it may make the client feel embarrassed or ashamed of the diagnosis. At home, the client can continue to follow a daily routine or written schedule that helps them stay on tasks and accomplish activities and responsibilities. It is not helpful for others to give unsolicited advice about other activities the client with OCD can engage in as this will add to the guilt and shame that people with OCD experience.
A nurse is working with a client who has been diagnosed with delusional thoughts. Which is an initial short-term outcome appropriate for this client?
A. Accept that the delusion is illogical
B. Distinguish external boundaries
C. Explain the basis for the delusions
D. Engage in reality-oriented conversation
Answer: D
Rationale: Delusions are not reality oriented; thus, an appropriate outcome would be that the client will engage in reality-oriented conversation rather than discussing delusional beliefs. Delusions are fixed, false beliefs. Clients rarely accept anyone using logic to dispute them. Data are not present to suggest boundary disturbance. Explaining the delusion is not progress; it suggests the client still holds to the belief.
A client with depression has been taking fluoxetine for the last 3 months and has noticed improvement of symptoms. The nurse inquiries about any side effects being experienced. Which side effect will the client likely report?
A. A headache after eating wine and cheese
B. A decrease in sexual pleasure during intimacy
C. An intense need to move about
D. Persistent runny nose
Answer: B
Rationale: Sexual dysfunction can result from enhanced serotonin transmission associated with SSRI use. Headache caused by hypertension can result when combining monoamine oxidase inhibitors with foods containing tyramine, such as aged cheeses and alcoholic beverages. SSRIs cause less weight gain than other antidepressants. Dry mouth and nasal passages are common anticholinergic side effects associated with all antidepressants. An intense need to move about (akathisia) is an extrapyramidal side effect that would be expected of an antipsychotic medication. Furthermore, sedation is a common side effect of fluoxetine.
A nurse is caring for a client with dependent personality disorder that is having difficulty making decisions related to leaving a tumultuous marital situation. Which action will be most therapeutic by the nurse?
A. Encourage the client to take the children and leave the abuser.
B. Teach problem-solving and decision-making skills.
C. Call a supporting family member to assist the client with personal issues.
D. Tell the client it is time to be independent and move on with life.
Answer: B
Rationale: Dependent personality disorder is characterized by a pervasive and excessive need to be taken care of, which leads to submissive and clinging behavior and fears of separation. These behaviors are designed to elicit care taking from others. The dependent person must rely on others to make decisions and assume responsibility of major areas of life. The nurse should help the client by teaching them independence and problem-solving and decision-making skills. The nurse should not make decisions for the client or tell them to leave the situation. It is a violation of the client’s rights to notify a family member and will not help the client problem solve. Telling the client to be independent and move on with life is nontherapeutic and does not foster independence.
The nurse is educating a client with obsessive–compulsive disorder (OCD) about relaxation and behavioral techniques. Which information is important for the nurse to include when educating about these techniques? Select all that apply.
A. Use relaxation techniques when the anxiety level is low.
B. Use relaxation techniques when the client is experiencing anxiety.
C. Engage in exposure and response prevention.
D. Inform the client they will likely not get better if these techniques are used.
E. Assess the baseline of ritualistic behaviors in the client.
Answer: A, B, C, E
Rationale: The intervention should take place when the client's anxiety is low so they can learn more effectively. The nurse may teach the client about relaxation techniques when the client is experiencing anxiety. The client must be willing to engage in exposure and response prevention in order to achieve recovery. The client cannot be forced to use relaxation techniques because they would be ineffective. It is necessary to assess the baseline of frequency and duration of anxiety and ritualistic behaviors in the client with OCD so the nurse can gauge progress.
The nurse suspects that a client taking an antipsychotic medication for the treatment of schizophrenia is having drug-induced parkinsonism. Which finding(s) assessed by the nurse will correlate with this disorder? Select all that apply.
A. Facial expressions are mask-like with little emotion observed.
B. The fingers are making a pill rolling motion.
C. The client is having drooling from the side of the mouth.
D. The client has a resting heart rate of 102 beats per minute.
E. The client demonstrates a slowness and difficulty initiating movements.
Answer: A, B, C, E
Rationale: A masklike facies, cogwheel rigidity (ratchet-like movements of joints), drooling, muscle stiffness (continuous), and akinesia (slowness and difficulty initiating movement) are all symptoms of pseudoparkinsonism, or neuroleptic-induced parkinsonism. Tachycardia is not a symptom of pseudoparkinsonism.
A client is providing discharge education to a client taking lithium at home for the treatment of bipolar disorder. Which client statement(s) indicate the education is effect? Select all that apply.
A. “I will weigh myself weekly at the same time of day.
B. “Hydration is important with at least 2 L of decaffeinated fluid daily.”
C. “It is not necessary to alter my dietary salt intake.”
D. “If I get sick with the flu, I will notify my health care provider.”
E. “I will engage in strenuous exercise frequently to keep my weight down.”
Answer: B, C, D
Rationale: Clients should drink adequate water (approximately 2 L/day) and continue with the usual amount of dietary table salt. Having too much salt in the diet because of unusually salty foods or the ingestion of salt-containing antacids can reduce receptor availability for lithium and increase lithium excretion, so the lithium level will be too low. If there is too much water, lithium is diluted, and the lithium level will be too low to be therapeutic. Drinking too little water or losing fluid through excessive sweating, such as with strenuous exercise, vomiting, or diarrhea increases the lithium level, which may result in toxicity. Monitoring daily weights and the balance between intake and output and checking for dependent edema can be helpful in monitoring fluid balance. The health care provider should be contacted if the client has diarrhea, fever, flu, or any condition that leads to dehydration.
The nurse is working with clients with personality disorders that are having problems with relationships and other parts of their life. Which barrier(s) are the nurse experiencing when working with this group of clients? Select all that apply.
A. Clients fail to understand the need to change their behavior.
B. There is a slow progress and clients stop seeking help for issues.
C. It is difficult to change personality traits since they are deeply embedded.
D. The clients may take pride in some of the personality traits they have.
E. Clients with personality disorders are always receptive to treatment.
Answer: A, B, C, D
Rationale: People with personality disorders are often described as “treatment resistant.” This is not surprising, considering that personality characteristics and behavioral patterns are deeply ingrained. It is difficult to change one’s personality; if such changes occur, they evolve slowly. The slow course of treatment can be frustrating for family, friends, and health care providers. Another barrier to treatment is that many clients with personality disorders do not perceive their dysfunctional or maladaptive behaviors as a problem and this may be why they are resistant to treatment. Sometimes these behaviors are a source of pride and this makes the client not as receptive to therapy and treatment.