Obsessive-Compulsive Disorder - Case Study - NRSG347
The nurse recognizes a need to educate Britney on the dangers of stopping her medication without the supervision of her psychiatrist. The nurse makes a decision to wait until a later time to provide this education. Which rationale is the basis for the nurse's decision? a) Because of HIPAA concerns, Britney's education should be provided in private without the presence of family members b) Britney has already weaned herself off the medication without a problem, so education at this point is not warranted c) Britney is currently experiencing severe to panic levels of anxiety, so education with be ineffective d) It is important to know what medications Britney will be prescribed prior to completing education
Britney is currently experiencing severe to panic levels of anxiety, so education will be ineffective
The nurse notifies the psychiatrist about the ECG results. The psychiatrist will be in soon to see Britney, and then attend the treatment team meeting. In preparation for the daily team meeting, the nurse completes a review of Britney's medications and notes that aripiprazole (Abilify) has a potential side effect of elongated QT syndrome. The nurse also notes that paroxetine (Paxil) can potentiate the effects of aripiprazole (Abilify). During the treatment team meeting, the nurse shares these concerns. Which is an accurate statement regarding the nurse's action of discussing these concerns with the treatment team? a) The nurse is practicing outside the scope of practice for nursing and should trust that the psychiatrist knows the medications being prescribed. b) The nurse should verify the concerns with the pharmacist prior to bringing concerns to the treatment team c) The nurse is performing a needed medication reconciliation and advocating for this client d) The nurse is demonstrating poor communication skills by embarrassing the psychiatrist and pointing out the medication issues
The nurse is performing a needed medication reconciliation and advocating for this client
Britney takes the lorazepam (Ativan) from the nurse and then asks how the medication will help and how soon it will work. Which response by the nurse regarding lorazepam (Ativan) is accurate? a) Lorazepam (Ativan) helps control the obsessive thoughts associated with your obsessive-compulsive disorder and with continued use will improve your symptoms over time b) Lorazepam (Ativan) will help control your anxiety making you feel calmer and it works within 20-30 minutes when taken orally c) Lorazepam (Ativan) will help you sleep and will be given daily at bedtime. It usually works within an hour. d) Lorazepam (Ativan) will help you focus and help clear up irrational thinking. It builds up in the system over time and will begin working within 1 to 2 weeks.
Lorazepam (Ativan) will help control your anxiety making you feel calmer and it works within 20-30 minutes when taken orally.
Later in the day, the nurse meets with Britney to discuss her rituals and how it is affecting her group attendance. Britney states that she has to wash her hands 10 times whenever she touches something that she considers contaminated. The nurse agrees to give Britney 30 minutes notice before groups to allow enough time for Britney to complete her rituals. Britney states that she knows it sounds ridiculous, but unless she completes the ritual she feels like she is covered in filth that will give her a deadly disease. Which nursing response is therapeutic regarding Britney's fear about being covered in filth that will give her a deadly disease? a) "It is ridiculous to think that, so it is good you are recognizing that Britney. It shows you are making progress." b) "Why do you need to wash your hands 10 times? Isn't once enough to prevent disease?" c) "You should read about how deadly diseases are transmitted so you don't have these fears. I can provide you readings that will help you understand this better." d) "That must be very frightening for you."
"That must be very frightening for you."
Britney has been taking the paroxetine (Paxil) for one week, and also taking lorazepam (Ativan) as needed for anxiety. She tells the nurse that the paroxetine (Paxil) isn't helping her OCD and that she is having headaches and nausea every day since starting it. How should the nurse respond to Britney? a) "You should be feeling an improvement in symptoms by this time. I will talk to the psychiatrist about your concerns so that a different medication can be considered." b) "It may take longer for the medication to work, but because you are experiencing side effects, it may be necessary to speak with the psychiatrist about changing to a different medication." c) "You need to give the medication a chance to work. The side effects will eventually go away." d) "The paroxetine (Paxil) may not be effective yet. Until the side effects go away in a few weeks, taking the medication with food may help."
"The paroxetine (Paxil) may not be effective yet. Until the side effects go away in a few weeks, taking the medication with food may help."
The psychiatrist meets with Britney and decides to add a low dose antipsychotic to help control the symptoms of OCD. The psychiatrist prescribes aripiprazole (Abilify) 2 mg at bedtime daily. The psychiatrist also prescribes gabapentin (Neurontin) 100 mg four time daily to help treat the generalized anxiety disorder. Britney's mother calls to check with the nurse on Britney's progress. Britney has signed full releases of information for both her parents. The nurse shares that the psychiatrist has prescribed the new medications for Britney, and the mother expresses concern regarding the addition of two medications. Which initial response by the nurse is indicated? a) "The psychiatrist is excellent and you can trust that your daughter is receiving great care." b) "Britney's symptoms are severe and these medications are necessary to get her back on track." c) "You have concerns about how Britney will respond to these medications." d) "It is very normal for clients with OCD and GAD to have these medications prescribed, so you don't need to worry."
"You have concerns about how Britney will respond to these medications."
The medication becomes available and the nurse partially open the packet containing the oral lorazepam (Ativan) 2 mg. The nurse empties the medication into a paper medication cup then hands the cup to Britney with a glass of water. Britney refuses to take the medication cup, and backs away from the nurse stating, "I heard you coughing earlier. I don't want to take it from you." Which is an indicated response from the nurse in this situation? a) "I can empty it into your hand without contacting the pill" b) "You need this medication to reduce your anxiety. If you don't take it, we will have to give you a shot instead." c) "I didn't touch the pill and you won't get a cold just from touching the cup." d) "Why are you concerned about my cough."
"I can empty it into your hand without contacting the pill."
By the end of the week and with the support of the staff, Britney is able to reduce time spent on rituals by washing her hands 7 times instead of 10. However, Britney continues to feel depressed, and shares that she thinks about suicide at least once a day. "I'm trying, but it's so hard trying to control my mind." Which interventions are important for the nurse to employ at this time? (Select all that apply) a) Ask Britney if she has a plan for how she would commit suicide b) Reassure Britney that she will soon be feeling much better since she is taking medications c) Acknowledge progress Britney has made in reducing time spent on rituals d) Explore the intent of Britney's statement about trying to control her mind. e) Divert Britney's attention to more positive topics to avoid ruminating on negative feelings
-Ask Britney if she has a plan for how she would commit suicide -Acknowledge progress Britney has made in reducing time spent on rituals -Explore the intent of Britney's statement about trying to control her mind
The psychiatrist has been increasing Britney's medications in increments over the course of her hospitalization. She is now on paroxetine (Paxil) 40 mg, gabapentin (Neurotin) 800 mg, aripiprazole (Abilify) 10 mg, and lorazepam (Ativan) 1 mg as needed. With Britney's input into her treatment plan, daily exercise as a therapeutic intervention is implemented. While walking on the treadmill, Britney falls and scrapes her knees requiring bandages. Which considerations are important in Britney's care at this point? (Select all that apply) a) Exercise should be restricted to prevent further injuries b) Assessment of factors related to Britney's fall should be completed c) A fall risk assessment should be completed d) Britney's medications will likely require adjustment e) Education on use of equipment should be provided to Britney
-Assessment of factors related to Britney's fall should be completed -A fall risk assessment should be completed -Education on use of equipment should be provided to Britney
Britney follows up with her family physician in 1 month regarding her ECG. He repeats a 12 lead ECG that shows a normal QT, but the frequent PACs and PVCs continue to be present. He refers her to a cardiologist, who plans for Britney to have an echocardiogram. This shows no abnormalities in Britney's heart structure. A second appointment to discuss the results of her tests is scheduled for 1 week later. At the appointment, the nurse obtains vital signs, which are all within normal limits, and then obtains a history from Britney. As an integral aspect of interprofessional collaboration, which information obtained from Britney's history should the nurse distinguish as being significant to share with the physician? (Select all that apply) a) Britney's mother has a history of receiving treatment for heart palpitations b) Britney defines ever having consumed alcohol, smoked tobacco, or taken any form of street drug c) Britney had chicken pox as a child d) Britney is not sexually active e) Britney's vital signs are within normal limits
-Britney's mother has a history of receiving treatment for heart palpitations -Britney denies ever having consumed alcohol, smoked tobacco, or taken any form of street drug -Britney's vital signs are within normal limits
After a 9-day hospitalization, Britney is discharged to home with her parents. Which information should be included in the discharge plan? (Select all that apply) a) Follow up appointments with psychiatrist and therapist b) Appointment with family physician to follow up on the cardiac abnormalities c) Contact information for staff who have worked with Britney on the unit d) Information on all current medication e) Coping skills Britney can use when under stress
-Follow up appointments with psychiatrist and therapist -Appointment with family physician to follow up on the cardiac abnormalities -Information on all current medication -Coping skills Britney can use when under stress
Britney is readmitted to the psychiatric inpatient unit, and routine tests of CBC, Chemistry panel, drug screen, Vitamin D level, and ECG are being obtained. All blood work comes back within normal levels, but the nurse reviewing the test results notes that the ECG shows a marked change from the initial ECG done during Britney's previous admission. The ECG shows a significant elongation of QT segments with frequent premature atrial contractions (PVC) and premature ventricular contractions (PAC). Which actions are indicated for the nurse to take? (Select all that apply) a) Notify the psychiatrist of the test result b) Withhold all medications until the psychiatrist sees Britney c) Give a PRN lorazepam (Ativan) to reduce anxiety which will reduce the cardiac symptoms d) Do nothing, as these are not harmful rhythms e) Evaluate medications that Britney is taking for possible side effects
-Notify the psychiatrist of the test result -Evaluate medications that Britney is taking for possible side effects
Britney's anxiety gradually subsides, with only occasional panic attacks and mild to moderate anxiety levels that she is able to manage. She denies suicidal ideations at the current time, and states the depression she experienced has evolved into a "numb" feeling. The psychiatrist, nurse, and social worker meet with Britney and her parents to discuss possible discharge within the week. Britney's mother expresses concern because she has noticed that the muscles in Britney's leg seems to be twitching, and points this out to the psychiatrist. The psychiatrist adds benztropine (Cogentin) 2 mg PRN to Britney's medications. Which should the nurse recognize as being the purpose of this medication in Britney's case? a) Benztropine (Cogentin) is likely being prescribed to help Britney's feeling of emotional numbness b) The muscle twitching may be due to deficiencies in Britney's diet, and benztropine (Cogentin) can help correct these deficiencies c) The muscle twitching is likely a physiological response to Britney's chronic anxiety and benztropine (Cogentin) can reduce this response d) Aripiprazole (Abilify) can cause a side effect of muscle trembling or jerking and benztropine (Cogentin) can reduce this side effect.
Aripiprazole (Abilify) can cause a side effect of muscle trembling or jerking and benztropine (Cogentin) can reduce this side effect
Britney has now been hospitalized for 3 weeks. Her anxiety has lessened, though she has panic attacks 1 to 2 times a day. She continues to have depression and has started refusing to attend some of the scheduled group sessions, stating the groups are repetitive and that she feels worse after hearing other clients' stories. Britney does note that the medication teaching groups are helpful and she enjoys recreation therapy. Which approach by the nurse is indicated at this time? a) Tell Britney to attend the groups that she finds beneficial b) Tell Britney that groups are required and that refusal to attend will be reported to the psychiatrist and her parents c) Ask Britney why she is refusing groups since this is what will help her get better d) Ask Britney to provide input into her treatment plan
Ask Britney to provide input into her treatment plan
The psychiatrist completes an assessment and admits Britney to the inpatient adult unit. After the admitting procedures are complete, Britney's parents leave for home and Britney immediately becomes increasingly agitated, and begins crying and hyperventilating. The nurse informs Britney that the psychiatrist is writing prescriptions for medication to help alleviate the anxiety and will check on the status of the prescription, and be back with the medication as soon as it is available. Which nursing action is indicated next? a) Check Britney's electronic medical record (EMR) to see if medication has been prescribed b) Wait at least 15 minutes before giving any medication because Britney's anxiety may be a short-lived response to her parents leaving c) Tell Britney to lie down and try to relax until the nurse returns with the medication d) Ask another nurse to check on the status of the medications prescribed and return to Britney's room and stay with her.
Ask another nurse to check on the status of the medications prescribed and return to Britney's room and stay with her
The cardiologist recommends a 24 hour Holter monitor and the nurse attaches the leads to Britney before she leaves. A week later Britney returns to the cardiologist for results. The Holter monitor shows over 30,000 PVCS and PACs. The cardiologist prescribes atenolol (Tenormin) 50 mg daily. After the cardiologist leaves the room, Britney asks the nurse how this medication will help. Which is an accurate response to Britney's question? a) Atenolol (Tenormin) is an anxiolytic that will relieve your anxiety so that the heart palpitations will lessen b) Atenolol (Tenormin) is a calcium channel blocker that can put your heart in a normal rhythm c) Atenolol (Tenormin) is a beta blocker that helps slow and steady your heart's rhythm and in some cases also helps reduce anxiety d) Atenolol (Tenormin) is a loop diuretic that will make your heart pump more easily reducing your cardiac symptoms
Atenolol (Tenormin) is a beta blocker that helps slow and steady your heart's rhythm and in some cases also helps reduce anxiety
The nurse suggests to Britney that she try washing her hands only 9 times the next time instead of 10. Britney agrees to try this. Which response does the nurse anticipate Britney will have as she attempts to reduce the number of hand washings? a) Britney most likely will not follow through on the plan to reduce the hand washings b) Britney may have reduced anxiety c) Britney may have increased anxiety d) Britney will likely not have any change in response when reducing the ritual
Britney may have increased anxiety
The psychiatrist tells Britney to stop taking the benztropine (Cogentin) and see if the urinary issues resolve. Britney is instructed to call the office if the muscle twitching returns or if the difficulty in urination persists after stopping the medication. Britney stops the medication, and within a day is able to urinate without difficulty. She does not notice any return of the muscle twitching. However, Britney continues to feel emotionally numb and this is starting to become troubling to her and her parents. At her next monthly appointment, the psychiatrist suggests tapering the gabapentin (Neurontin) now that the paroxetine (Paxil) is working. As the gabapentin (Neurontin) is reduced over the next month, the emotional numbness seems to subside for Britney. However, she is noticing a return of depression and feelings of extreme fatigue. She has also noticed that her heart feels like it is skipping beats, and that it feels like it is fluttering. Britney sometimes wakes in the night with these symptoms and it causes her anxiety. Britney's mother also notices Britney is spending more time isolating and that she is having tearful episodes daily. An appointment with the psychiatrist is arranged and Britney's mother accompanies her to the appointment. As the nurse completes her initial assessment, Britney reveals that she has been feeling extremely depressed with suicidal ideation. She states she has thought of ways to kill herself, but prefers not to talk about that. Which outcome does the nurse anticipate from this appointment? a) Gabapentin (Neurontin) to be restarted on an outpatient basis b) Britney will be readmitted to the psychiatric inpatient facility c) Lorazepam (Ativan) as needed will be prescribed for Britney to take when she feels increased anxiety d) Britney's therapy appointments will be increased to twice weekly
Britney will be readmitted to the psychiatric inpatient facility
Britney is discharged to home with her parents. She has a follow up in 1 week with a psychiatrist at the outpatient clinic, as well as scheduled sessions with an outpatient therapist. At her 1 week visit Britney is first seen by the intake nurse. She tells the nurse that she is doing well, but does report difficulty urinating and continued feelings of emotional numbness. She states she is so relieved to be home that it isn't bothering her too much. The nurse asks Britney how she has been spending her time since discharge and Britney states she has been watching TV and just trying to stay relaxed by listening to music and sitting with her dog. Britney reports that her appetite hasn't really returned yet, and she is primarily drinking protein shakes, and eating cereal and yogurt. Which should be the nurse's priority concern at this time? a) Britney's lack of exercise b) Britney's dietary needs c) Britney's difficulty urinating d) Britney's feelings of emotional numbness
Britney's difficulty urinating
Britney's side effects of nausea and headache are diminishing, but since starting the 2 new medications she is bothered by sleepiness and lack of energy. She states this is adding to her hopeless and helpless feelings. Britney continues to be depressed and at times expresses suicidal ideations. Britney refuses to attend some of the group sessions on the unit, stating that she feels more stressed after attending. It is time for the next group session and the nurse goes to Britney's room to let her know group will start in 5 minutes. Britney is vigorously washing her hands and does not respond. How should the nurse respond to Britney's lack of response? a) Ask Britney if she heard that the group was in 5 minutes b) Leave Britney and continue to let other clients know that group will start in 5 minutes c) Warn Britney that if she doesn't attend groups, her insurance will likely not cover her stay on the unit d) Tell Britney that groups are intended to help her get better, and that it is part of her treatment plan to attend
Leave Britney and continue to let other clients know that group will start in 5 minutes
Britney sleeps through the night, but awakens the next morning with heightened anxiety and an impending sense of doom. She approaches her assigned nurse and requests another lorazepam (Ativan), stating it helped her so much when she took it the previous evening. The nurse administers a PRN lorazepam (Ativan) and after Britney is calmer, sits down with Britney to further evaluate her needs. The nurse notes that Britney is a vegetarian and has lost 10 pounds in the last 3 weeks. Britney also admits to spending most of her time indoors and primarily eating foods high in carbohydrates. She eats no vegetables and only occasionally eats fruit. Based on Britney's history and the nursing assessment, which vitamin and minerals levels might be expected? a) Low levels of vitamin D, B, and magnesium b) Low vitamin D, high vitamin B levels, and normal magnesium levels c) High levels of magnesium and B vitamin, and low levels of D vitamin d) Normal levels of magnesium and B vitamin, and low levels of D vitamin
Low levels of vitamin D, B, and magnesium
The nurse reviews Britney's CBC, chemistry panel, vitamin D level, and an ECG that were done on admission. The blood tests reveal a low vitamin D level of 6 ng/mL, but all other levels and the ECG were within normal limits. Britney meets with the psychiatrist who prescribes a high dose vitamin D supplement and also recommends starting paroxetine (Paxil), a medication to help with her obsessive-compulsive disorder. Which information is accurate for the nurse to share with Britney to help her understand why paroxetine (Paxil) is prescribed? a) Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) antidepressant that has been approved by the Food and Drug Administration (FDA) for use in treating OCD, and generalized anxiety disorder (GAD) b) Paroxetine (Paxil) is a tricyclic antidepressant that has an off-label use of treating OCD and panic disorder c) Paroxetine (Paxil) belongs to a class of antianxiety medications known as benzodiazepines and has been approved by the Food and Drug Administration (FDA) for the treatment of OCD and general anxiety disorder (GAD). d) Paroxetine (Paxil) is an antipsychotic medication that helps to eliminate the irrational obsessions associated with OCD, which in turn helps reduce anxiety
Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) antidepressant that has been approved by the Food and Drug Administration (FDA) for use in treating OCD, and generalized anxiety disorder (GAD)
The nurse completes an initial nursing intake assessment. When asked what brought her to the hospital, Britney replies, "I can't stop worrying about everything. It's so bad I don't even want to get out of bed anymore" and she begins to cry. Britney admits to having had obsessive-compulsive disorder in the past and she had been taking fluvoxamine (Luvox) for four years. She states she weaned herself off the medication 2 months ago because she was starting college and the medication made her tired. "I couldn't handle college though and now I feel like a big failure. I'm just taking up space. I'm no good to anyone." Which nursing concern should take priority? a) Lack of compliance with her medication for obsessive-compulsive disorder b) Potential risk for suicide c) Inability to follow through with life goals d) Ongoing worry that is affecting daily functioning
Potential risk for suicide
The psychiatrist acknowledges that the nurse's review of Britney's medications is accurate and likely contributing to Britney's feelings of depression, as well as her cardiac abnormalities. The psychiatrist expresses appreciation for the nurse bringing the medication concerns to the attention of the team. Britney's dose of aripiprazole (Abilify) is adjusted with the intent to completely wean her from the medication within the next 2 weeks. Britney has a marked improvement in mood within 1 week of the medication adjustment, and is asking to be discharged. However, she continues to feel her heart skipping beats and fluttering frequently throughout the day. Which is most critical to assess prior to discharge? a) Presence of suicidal ideations b) A repeat ECG c) Anxiety levels d) Discharge plans are in place
Presence of suicidal ideations
Britney's parents live 2 hours away and cannot visit every day. They have been laundering Britney's clothes, but Britney has run out of socks. An Unlicensed Assistive Personnel (UAP) insists that Britney use the washer available to clients to wash her clothes, but Britney is resistant due to her fear of contamination from others' clothes having been in the machine. The UAP continues to insist that Britney wash her clothes and refuses to provide her a pair of hospital slippers. Britney's nurse overhears the exchange. Which action by the nurse shows effective use of interprofessional collaboration? a) Pulling the UAP aside and providing information on obsessive-compulsive disorder and the importance of avoiding power struggles b) Do nothing as the UAP acted correctly c) Provide Britney hospital slippers once the UAP has left the area d) Report the behavior of the UAP to the charge nurse
Pulling the UAP aside and providing information on obsessive-compulsive disorder and the importance of avoiding power struggles
Britney has been in the hospital for 2 weeks. The addition of aripiprazole (Abilify) and gabapentin (Neurotin) seem to have lessened Britney's anxiety, and she is taking less of the lorazepam (Ativan) PRN. Despite a lessening of anxiety, Britney continues to have a fear of contamination from germs and requests the nurses wear gloves when preparing her medication; she will not accept medication from nurses who have a cold. Britney comes to the nurses' station to receive her evening medications, and requests that the nurse put on gloves. The nurse refuses and states, "I am not sick, and if you don't take the medication, I will write 'refused' in your chart." Britney begins having a panic attack, and sits on the floor hyperventilating and sobbing. A new nurse on the unit who observes this interaction, later questions this approach. Which approach should be helpful for the new nurse to use if handling a similar situation in the future? a) Put on gloves to administer the medication b) Do not put on gloves to administer the medication, and write "refused" in the medication record c) A client's childish behaviors should be pointed out so that the client can work on changing the behavior d) The nurse should comply with a client's request to wear gloves, but the nurse should make the client aware the behavior will need to be reported to the psychiatrist
Put on gloves to administer the medication
Britney begins crying and tells the nurse she needs her lorazepam (Ativan) as it's the only thing that helps her. The nurse checks the medication administration record to determine Britney's last dose of lorazepam (Ativan) and how often it is prescribed. Noting it can be given every 8 hours PRN, and the last dose was given over 12 hours ago, the nurse begins to pull the medication from the Pyxis. The charge nurse on the unit notices this and interjects that Britney is becoming dependent on the lorazepam (Ativan) and that she doesn't appear to have a high anxiety level at the present time. The charge nurse tells the nurse to not give the medication at this time. Which approach should be taken by the nurse caring for Britney in this situation? a) Follow the charge nurse's directive and tell Britney she cannot give her the medication at this time. b) Ignore the charge nurse and continue to pull the medication from the Pyxis c) Share the assessment of Britney's anxiety level and remind the charge nurse that no medication has been given in the last 12 hours d) Review the drug resource information and based on the stated potential for dependency to lorazepam (Ativan), explain to Britney that she should not take the medication so frequently
Share the assessment of Britney's anxiety level and remind the charge nurse that no medication has been given in the last 12 hours
Which is the most likely cause of Britney's difficulty in urinating? a) Kidney function impaired from numerous medications b) Physiological response to anxiety of being discharged c) Side effect of benztropine (Cogentin) d) Lack of fluid intake
Side effect of benztropine (Cogentin)