Compulsive Disorder (OCD)
by Mr. Suman Bera
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 - CORRECT ANSWERSPotential
risk for suicide
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 - CORRECT ANSWERSBritney is currently experiencing severe to panic
levels of anxiety, so education will be ineffective
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 retu -
CORRECT ANSWERSAsk another nurse to check on the status of the medications
prescribed and return to Britney's room and stay with her
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."