Ch. 20 Obsessive Compulsive and Related Disorders
Which client is most likely to benefit from the administration of selective serotonin reuptake inhibitors (SSRIs)? A) A client whose obsessive-compulsive disorder (OCD) has not responded to cognitive- behavioral therapy B) A client whose unusual pattern of hair loss has been attributed to a mental health disorder C) A client who has diffuse skin lesions as a result of excoriation disorder D) A client whose family is deeply concerned that the client may have hoarding disorder
A) A client whose obsessive-compulsive disorder (OCD) has not responded to cognitive- behavioral therapy Explanation: OCD is responsive to treatment with SSRIs. Trichotillomania, excoriation disorder, and hoarding are not normally treated with SSRIs.
The mental health nurse explains that the difference between an obsession and a compulsion can correctly be identified as what? A) A compulsion involves repeating a seemingly purposeful action. B) The client experiencing compulsions has insight into the disorder. C) An obsession responds well to psychiatric treatment. D) The client experiencing an obsession usually experiences delusions as well.
A) A compulsion involves repeating a seemingly purposeful action. Explanation: An obsession is a persistent, painful, and intrusive thought, emotion, or urge that the client is unable to suppress or ignore, while a compulsion is the performance of a repetitious, seemingly purposeful act to prevent some future event or situation.
A patient's mental health disorder is characterized by the patient's excessive cleaning of her surroundings. How can the nurse best address the biochemical aspects of the patient's disorder? A) Administer sustained serotonin reuptake inhibitors (SSRIs) as prescribed B) Dialogue with the patient about isolation, undoing, and reaction forming C) Educate the patient about the relationship between cerebral glucose metabolism and mental health D) Administer anticonvulsants as prescribed
A) Administer sustained serotonin reuptake inhibitors (SSRIs) as prescribed Explanation: The patient likely has obsessive -compulsive disorder, which is often treated with SSRIs, not anticonvulsants. Isolation, undoing, and reaction forming are components of psychodynamic theory. Neuropathologic theory focuses on the role of cerebral glucose metabolism.
A client with obsessive-compulsive disorder (OCD) performs lengthy handwashing rituals many times a day. The client will soon begin exposure and response prevention (ERP). What outcome should the nurse identify with the client when planning this intervention? A) Client will acknowledge that illness does not always result if she does not handwash B) Client will acknowledge that her handwashing rituals adversely affect her quality of life C) Client will describe the importance of adhering to the prescribed drug regimen D) Client will identify the relationship between obsessions and compulsions
A) Client will acknowledge that illness does not always result if she does not handwash Explanation: A key outcome of ERP is helping the client realize that abstaining from a compulsion does not result in catastrophe. It is important for a client to adhere to drug treatment, but this is not directly related to ERP. Clients are normally well-aware that their obsessions lead to their compulsions and that compulsions affect quality of life.
A client has been diagnosed with obsessive-compulsive disorder (OCD). What action by the nurse best addresses the behavioral factors that are believed to underlie the disease? A) Discussing the "payoff" of anxiety reduction that results from performing compulsions B) Identifying the coping strategies that exist in the client's family of origin C) Reviewing the results of the client's computed tomography with the primary care provider D) Assessing the response of the client's parents and siblings to the disease
A) Discussing the "payoff" of anxiety reduction that results from performing compulsions Explanation: Behavioral factors involved the application of learning theory. Essentially, compulsive behavior is reinforced by the reduction in anxiety that accompanies rituals. Diagnostic imaging is a focus of neuropathologic theories. Family responses are significant, but are not central to the behavioral theory that contributes to the disease.
The psychiatric mental health nurse is planning the care of a client whose elaborate room entry and exit rituals have led to a diagnosis of obsessive-compulsive disorder (OCD). What action by the nurse best addresses possible psychodynamic aspects of the etiology? A) Exploring the characteristics of the client's defense mechanisms B) Monitoring the client's blood glucose levels C) Discussing the client's relationship with her father D) Identifying the client's personality type
A) Exploring the characteristics of the client's defense mechanisms Explanation: Psychodynamic theory focuses on the role of defense mechanisms in the etiology of obsessive-compulsive disorder. Personality type and family relationships are not central to psychodynamic theory. Hyper- and hypoglycemia are not recognized etiologic factors.
Following an incident of self-harm, a client with obsessive-compulsive disorder is being admitted to the psychiatric unit. How should the nurse best address the client's anxiety around performing compulsive rituals in this unfamiliar setting? A) Give the client a clear and detailed description of unit routines B) Place the client in a room that is farther from the nurses' station, if possible C) Brief the other clients on OCD rituals, while maintaining confidentiality D) Teach the client thought stopping techniques upon admission
A) Give the client a clear and detailed description of unit routines Explanation: Unit routines should be clearly explained to a client with OCD in order to mitigate some of the anxiety that admission will provoke. The client is unlikely to be open to learning new cognitive techniques (thought stopping) during this time of transition. It is inappropriate to brief clients on another client's symptoms or illness. Locating the client far from the nurses' station has no benefit.
The psychiatric mental health nurse has received a referral from a community health nurse regarding a client who appears to have hoarding disorder. When planning this client's care, the nurse should prioritize what consideration? A) Promoting the client's safety in the home environment B) Teaching the client to differentiate between necessary and unnecessary items C) Educating the client about the use of relaxation techniques D) Collaborating with law enforcement while maintaining the client's autonomy
A) Promoting the client's safety in the home environment Explanation: Safety is a paramount consideration for clients with hoarding disorder. Clients are not normally open to differentiating between necessary and unnecessary items. Relaxation techniques are secondary to safety and there is not normally a need to involve law enforcement.
The psychiatric mental health nurse is performing a suicide assessment of a client who has obsessive-compulsive disorder (OCD). What data should the nurse prioritize in order to maximize the accuracy of this assessment? A) The amount of psychological distress that the client's compulsions cause B) The degree of insight into the disorder that the client possesses C) The client's current medication regimen D) The client's recent adherence to prescribed treatment
A) The amount of psychological distress that the client's compulsions cause Explanation: The anxiety that accompanies OCD does not normally lead directly to suicide. However, the risk is greatly heightened if the client has a high level of distress. Insight, adherence and medications are all important parts of a nursing assessment, but none is as directly related to the client's risk for suicide.
The psychiatric mental health nurse is preparing to interview a new client. What assessment finding should prompt the nurse to assess the client for signs and symptoms of obsessive-compulsive disorder? A) The client has a diagnosis of dependent personality disorder B) The client made a suicide attempt several years earlier C) The client's mother has been hospitalized for treatment of depression D) The client is dressing inappropriately for the weather
A) The client has a diagnosis of dependent personality disorder Explanation: About half of people with OCD have dependent personality disorder. For this reason, the client's diagnosis with this mental health disorder would be more significant than a family history of depression, a history of self-harm or inappropriate dress.
The client and nurse have interacted for several months in an outpatient behavioral health clinic. Which is the most important variable identified by the nurse in determining the likelihood of success in improving life for this client with obsessive-compulsive disorder (OCD)? A) The client must be willing to make changes in their behavior. B) The client must acknowledge that the behavior is not in their control. C) The client must allow the nurse to decide the appropriate intervention. D) The client must be willing to try all new relaxation techniques.
A) The client must be willing to make changes in their behavior. Explanation: The most important variable is that the client is willing to make changes in their behavior. In order to reduce the effect of the disease, the client must acknowledge that they can exert control over the rituals. The client and nurse together must determine which interventions will be used. The client will likely need to use relaxation techniques but should have input into deciding which ones.
The nurse is participating in an interdisciplinary care conference for a client who has obsessive-compulsive disorder (OCD). In order to best promote the client's recovery, the care team must: A) agree on consistent expectations for the client's behavior. B) establish meaningful consequences for the client in case of nonadherence. C) allow the client to lead the care conference and identify the desired outcomes. D) identify the precise etiology of the client's obsessive-compulsive disorder.
A) agree on consistent expectations for the client's behavior. Explanation: The care team must be agreed on the expectations for the client in order to promote recovery. It is not possible to identify the precise etiology of a multifactorial disease like OCD. The client's preferences and goals are important, but it is unrealistic to expect the client to lead an interdisciplinary care conference. Adherence is promoted through positive reinforcement, not negative consequences.
The nurse is interviewing a client who is suspected of having obsessive-compulsive disorder (OCD). The nurse suspects that the client is downplaying the frequency and complexity of her compulsions. In order to determine the exact frequency and complexity of the client's compulsions,which action by the nurse would be most appropriate? A) ask the client's permission for the nurse to discuss the matter with her family. B) ask the client to demonstrate the ritual during the interview. C) confirm what the client has described and document it. D) cross-reference what the client has said with previous health records
A) ask the client's permission for the nurse to discuss the matter with her family. Explanation: If the validity of a client's report is in doubt, it is reasonable and appropriate to corroborate with the client's family. Asking the client to demonstrate the ritual is impractical and does not necessarily replicate a typical compulsion. Previous records are usually unavailable, and if they are available they may not describe the client's current rituals.
The nurse has been working with a client who has obsessive-compulsive disorder (OCD) and the nurse is meeting the client's mother and father for the first time. During this interaction, the nurse should: A) assess the parents' willingness to assist with behavioral techniques the client has been taught. B) screen the client's mother and father for signs and symptoms of OCD. C) discuss the events in the client's childhood that may have caused OCD. D) teach the client's parents about the biochemical and neuropathologic factors that cause OCD.
A) assess the parents' willingness to assist with behavioral techniques the client has been taught. Explanation: Enlisting the help of the client's parents in his or her recovery is a priority. Screening them is not the nurse's priority, since the focus of care is the client. OCD is multifactorial and is not a direct result of childhood events. In most cases it is unnecessary for families to grasp the specific biochemical and neuropathologic factors that cause the disease.
The psychiatric mental health nurse has taught a client with obsessive-compulsive disorder (OCD) about the use of cue cards. This intervention will allow the client to: A) counter obsessive thinking with positive messages. B) review the negative consequences of compulsive rituals. C) understand the relationship between obsessions and compulsions. D) review his or her daily goals.
A) counter obsessive thinking with positive messages. Explanation: Cue cards are succinct reminders of positive messages aimed at empowering the client in his or her resistance to obsessive thinking. Cue cards do not record specific goals and do not focus on negative consequences. They do not directly address the harm of compulsions.
A client with obsessive-compulsive disorder has just been prescribed sertraline. When administering this medication, the nurse should: A) ensure the client knows that benefits will not be sensed for several weeks. B) assess the client's knowledge of necessary dietary modifications. C) dialogue about strategies for preventing weight gain. D) assess the client's knowledge of potential anticholinergic effects.
A) ensure the client knows that benefits will not be sensed for several weeks. Explanation: Sertraline is a sustained serotonin reuptake inhibitor (SSRI); SSRIs take weeks or months to have a therapeutic effect. Dietary modifications are unnecessary and the risk of weight gain is low. SSRIs do not cause anticholinergic effects.
A client with obsessive-compulsive disorder tells the nurse, "I never thought I'd be able to survive the feeling of leaving a room without going back through the door eight times, but I just did it with my therapist!" This client's treatment most likely included: A) exposure and response prevention. B) thought stopping. C) cue cards. D) progressive relaxation.
A) exposure and response prevention. Explanation: "Pushing through" a client's compulsion in order to face the resulting anxiety is characteristic of ERP. Thought stopping, cue cards and relaxation do not involve this direct form of confrontation with compulsions.
A client with obsessive-compulsive disorder has told the nurse, "Everyone's got routines. I don't see why everyone is so determined to focus on mine." The nurse should be aware that the client's behaviors would be categorized as compulsions because they: A) interfere with the client's quality of life. B) are outside of cultural norms. C) are performed on a regularly scheduled basis. D) address a fictitious threat.
A) interfere with the client's quality of life. Explanation: Compulsions are ritualized behaviors that interfere normal activities of daily living. The fact that they are outside of cultural norms is not a criterion for categorizing them as compulsions. Many routines are performed on a scheduled basis that are not compulsions. Some compulsions address genuine risks (e.g. risk of contamination) but the response to these risks is disproportionate.
The nurse is interviewing a client who is being treated for obsessive-compulsive disorder (OCD). The client's compulsions involve cleanliness rituals, which the client justifies by describing potential contaminants in great detail. The nurse interprets the client's statement as implying that: A) the client may lack insight into the diagnosis. B) the client's fears can likely be alleviated by presenting evidence about the safety of water. C) the client may develop more serious obsessions and compulsions over time. D) the client would likely benefit from inpatient treatment.
A) the client may lack insight into the diagnosis. Explanation: The client's attempt to justify the client's obsessions and compulsions suggests a lack of insight. This does not mean, however, that the client's disease will worsen over time or that inpatient treatment is needed. Objective evidence does not dissuade clients from their obsessions or rituals.
An older adult client is brought into the behavioral health outpatient clinic by a family member. The family member is concerned that the client is hoarding again. Which information obtained by the family member is of most concern to the nurse that correlates with the suspicion? Select all that apply. A) A large number of cats living in the home B) Unable to enter into the rooms due to clutter piled up C) When trying to remove items, the client becomes angry and upset. D) The client is obsessively cleaning the same areas repeatedly. E) The client is throwing away items in the home that are deemed "unnecessary."
A, B, C Explanation: Hoarding involves excessive acquisition of animals or apparently useless things; cluttered living spaces that become uninhabitable; and significant distress or impairment for the individual. Obsessive cleaning of the environment and disposing of articles that are of no value are not the characteristics of hoarding; the client usually exhibits the opposite behaviors.
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
B) A single path throughout the yard and house Explanation: 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.
Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash the hands for 14 minutes, comb the hair for 114 strokes, and switch the light off and on 44 times. Which intervention will the nurse include when planning the care of this client? A) Allow ample time for completion of all rituals before each meal. B) Gradually decrease the amount of time spent for performing rituals. C) Increase the client's acceptance of the need for medication to control rituals. D) Omit one ritualistic behavior every 4 days until all rituals are eliminated.
B) Gradually decrease the amount of time spent for performing rituals. Explanation: Ritualistic behaviors must be decreased gradually over time. The nurse must respect the client's choices, but allowing ample time for their completion may cause them to go unaddressed. Acceptance of medications is a means to reducing rituals, not an end to OCD behaviors. Dictating a reduction every 4 days is overly prescriptive; every client's needs and progress will differ. By placing a specific time frame for a goal to be met may increase the anxiety of the client.
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.
B) The importance of medication adherence and that it may be necessary for medication to be changed to find the one that works best. Explanation: 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 client with a diagnosis of obsessive-compulsive disorder (OCD) has been admitted to the psychiatric unit prior to undergoing psychosurgery. The nurse who is caring for this client should understand that: A) the client has recently been diagnosed with OCD. B) behavioral therapy and drug treatment have failed. C) the client likely has a comorbid diagnosis of depression. D) the client likely has a psychiatric advance directive (PAD) in place.
B) behavioral therapy and drug treatment have failed. Explanation: Psychosurgery is reserved for clients whose OCD has not responded to drug therapy and cognitive behavioral therapy. The client's diagnosis is likely longstanding. Comorbid depression is not an indication for psychosurgery. There is no obvious relationship between the use of psychosurgery and the existence of a PAD.
The nurse is providing care for a client who has a compulsive hair-pulling disorder. Which disorder should the nurse document for this client? A) hoarding B) trichotillomania C) excoriation disorder D) body dysmorphic disorder
B) trichotillomania Explanation: Trichotillomania (i.e., hair-pulling disorder) is described as the inability to stop recurrent pulling out of the hair that results in hair loss. It is related to emotional or anxiety release. Hoarding disorder is described as difficulty in discarding or parting with possessions with a strong need to save. Excoriation disorder (i.e., skin picking) is the inability to stop recurrent picking at the skin for emotional or anxiety release. Body dysmorphic disorder is a preoccupation with imagined or slight physical defects that are not apparent to others.
The nurse is assisting a client with obsessive-compulsive disorder (OCD) during a behavior therapy session. How does the nurse assist the client with "response prevention"? Select all that apply. A) Assist the client to confront situations that increase anxiety. B) Help the client to accept thoughts and related anxiety. C) Teach that anxiety will recede without disastrous consequences. D) Assist the client to take charge of thoughts and manage anxiety. E) Inform the client that the disorder is hereditary.
B, C, D Explanation: Behavior therapy includes exposure and response prevention. In response prevention, the client must accept thoughts and related anxiety. The client recognizes that anxiety is not disastrous and can be managed by controlling thoughts. The nurse introduces the client to behavior therapy by confronting situations that increase anxiety or "exposure." Although OCD is hereditary, it can be managed by SSRI antidepressants and behavior therapy.
The client has begun to wash the hands every hour due to the fear of germs becoming embedded in the client's skin leading the client to develop cancer. The nurse interprets this behavior as indicating which condition? A) An obsession B) A panic attack C) A compulsion D) Acute stress disorder
C) A compulsion Explanation: Compulsions are ritualistic behaviors that people feel compelled to perform either in accord with a specific set of rules or in a routine manner. A repeated action performed as the result of a persistent thought is termed a compulsion. Obsessions refer to recurrent, intrusive, and persistent ideas, thoughts, images, or impulses. Compulsions are the behaviors people with obsessive-compulsive disorder will carry out in order to neutralize the anxiety caused by the obsessions. Panic attacks typically are characterized by a discrete period of intense apprehension or terror without any real accompanying danger, accompanied by at least four of 13 somatic or cognitive symptoms. Acute stress disorder occurs within the first month of exposure to extreme trauma: combat, rape, physical assault, near-death experience, or witnessing a murder.
A teenage girl has been diagnosed with obsessive-compulsive disorder (OCD) that manifests with excessive handwashing. The client's father is exasperated, stating, "The simplest solution would be to take away her access to soap and water." How should the nurse best interpret the father's suggestion? A) This action would cause the client significant anxiety and distress B) The client would likely replace her handwashing compulsion with another compulsion C) This action would exacerbate the long term severity of the client's compulsion D) This action would relieve be effective but unethical
C) This action would cause the client significant anxiety and distress Explanation: Blocking a client's compulsions is not an effective solution and would cause the client stress and anxiety. Typically, the client would not choose an unrelated compulsion. The client's anxiety would be heightened in the short term, but would be less likely to effect the long term course of the disease.
The nurse is providing education to a client prescribed clomipramine to help with obsessive-compulsive disorder. Which statement by the client indicates the teaching was effective? A) "I should be feeling better in a week once I am on the medication." B) "I will not feel sleepy as a side effect of the medication." C) "I should take the medication on an empty stomach. D) "I may have a risk of suicidal thoughts with the medication."
D) "I may have a risk of suicidal thoughts with the medication." Explanation: The client would have a risk of suicidal thoughts so needs to be aware so that these can be reported to the healthcare provider. The medication would take usually several weeks before the client notices therapeutic effects so should not expect to feel better in a week. The medication also has a side-effect of sedation so that the client should be careful with driving and operating heavy machinery. The medication is best taken with food, not on an empty stomach.
The nurse is assessing a client who has been in the clinic multiple times with the report of a large bump on the nose, but the nurse does not see the area the client is pointing to. The client states, "How can you not see it! It is huge and hideous. I want it off!" Which is the best response by the nurse to the client? A) "There is nothing on your nose and you keep coming back reporting this." B) "There is no reason for you to continue to return when there is nothing we can do." C) "Your health care provider will not perform a surgical procedure unless something is found." D) "It seems as though you are worried about this bump and although I do not see it, it upsets you."
D) "It seems as though you are worried about this bump and although I do not see it, it upsets you." Explanation: Body dysmorphic disorder is a preoccupation with imagined or slight defect in physical appearance that causes significant distress for the individual and interferes with functioning in daily life. The nurse acknowledges the client's perceived issue as something that is concerning but does not acknowledge the reality of the "bump." The nurse should not argue with the client or inform them that there is nothing to be done. It would be prudent for the health care provider to make a referral to a mental health specialist.
The nurse is caring for a client with obsessive-compulsive disorder. During the treatment team meeting, the nurse shares frustration as to the client's inability to stop washing the hands. Which is the best response by the team leader? A) "The hand washing represents a way to exert independence from the staff." B) "The client is not aware of the excessive hand washing." C) "The client does not think anything is abnormal with washing the hands repeatedly." D) "The client feels guilt but cannot stop washing the hands to try to get rid of anxiety."
D) The client feels guilt but cannot stop washing the hands to try to get rid of anxiety." Explanation: Clients are often acutely aware of their compulsions and lament their effect on their lives. However, they may feel powerless to abstain from them. Compulsions are not an effort to exert independence from others; their motivation is internal. Clients usually recognize that their behavior is compulsive and abnormal but are powerless to stop the behaviors.
A client with obsessive-compulsive disorder (OCD) states making a concerted effort to reduce the frequency and duration of rituals. What intervention should the nurse include to assist in these efforts? A) Teach the client nonpharmacologic relaxation techniques B) Administer mood stabilizers as prescribed C) Teach the client how to complete the client's rituals in less time D) Educate the client about the negative effects of obsessions and compulsions
Teach the client nonpharmacologic relaxation techniques Explanation: Reducing the frequency of rituals for a person with OCD causes anxiety. Clients consequently benefit from learning techniques that can reduce their stress in a healthy way. Mood stabilizers are not typically used in the treatment of OCD, and nurses do not normally facilitate the performance of rituals. The client is likely aware of the negative consequences of obsessions and rituals, as evidence by efforts to eliminate them.
