# A nurse is caring for a client with obsessive-compulsive disorder (OCD) who performs repetitive hand-washing rituals that take 2-3 hours daily. Which nursing intervention would be most therapeutic for this client?

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## 문제

A nurse is caring for a client with obsessive-compulsive disorder (OCD) who performs repetitive hand-washing rituals that take 2-3 hours daily. Which nursing intervention would be most therapeutic for this client?

The client reports feeling anxious when unable to complete the hand-washing routine and has developed skin irritation from excessive washing.

## 보기

1. Immediately stop the client from performing the hand-washing ritual to break the cycle
2. Gradually reduce the time allowed for hand-washing rituals while teaching alternative coping strategies **✔ 정답**
3. Allow unlimited time for hand-washing to reduce the client's anxiety levels
4. Isolate the client from triggers that might initiate the compulsive behavior

**정답: 2**

## 해설

Gradual exposure and response prevention (ERP) is most therapeutic for OCD, as it systematically reduces ritual time while teaching coping strategies to manage anxiety without rituals.

## 심화 해설

Therapeutic Communication & Behavioral Strategy for OCD

For a client with obsessive-compulsive disorder (OCD) whose compulsive hand-washing consumes 2–3 hours daily, the most therapeutic nursing intervention is to gradually reduce the time allowed for the ritual while teaching alternative coping strategies.

OCD is maintained by a cycle where obsessions (intrusive, anxiety-provoking thoughts about contamination) trigger compulsions (hand-washing) that temporarily relieve anxiety. This negative reinforcement makes the ritual highly resistant to sudden cessation. Evidence-based clinical practice guidelines emphasize that management should be structured and phased, using a combination of Exposure and Response Prevention (ERP) and cognitive-behavioral techniques [1].

Immediately stopping the ritual (option 1) is contraindicated because it constitutes a forced "flooding" approach without the client's consent or coping skills. This would cause a severe spike in anxiety, potentially leading to panic, aggression, or a breakdown of the therapeutic nurse-client relationship. The guidelines stress that treatment must be collaborative and paced according to the client's tolerance [1].

Allowing unlimited time (option 3) is non-therapeutic as it reinforces the maladaptive behavior and allows the disorder to maintain its grip. The skin irritation indicates a physical consequence of the ritual, making it imperative to limit the behavior for physiological safety. Isolating the client from triggers (option 4) is a form of avoidance that provides only temporary relief and fails to build the client's internal capacity to manage anxiety; it is not a recommended long-term strategy in evidence-based frameworks [1].

The correct intervention aligns with a graded ERP approach. By gradually reducing the ritual time, the nurse helps the client tolerate increasing levels of anxiety without performing the compulsion, leading to habituation. Simultaneously teaching alternative coping strategies—such as deep breathing, guided imagery, or progressive muscle relaxation—equips the client with adaptive tools to manage the distress that arises when the compulsion is delayed or limited. This dual approach addresses both the behavioral pattern and the underlying anxiety, which is the cornerstone of evidence-based OCD management [1].

References (research sources)

- [1]Clinical practice guidelines for obsessive-compulsive disorder: 2025 update.GuidelineArumugham SS, Narayanaswamy JC, Balachander S, Sharma E, Jaisoorya TS, Reddy SC, Siddiqui AM, Desouza A, Shah PS, Reddy YJ. (2026) · DOI: 10.4103/indianjpsychiatry_1259_25

## 임상 시나리오

Managing Compulsive Rituals in OCDA phased approach using limit-setting and coping skills
Structure interventions using Exposure and Response Prevention (ERP) by negotiating a gradual reduction in ritual time, not an immediate halt. This prevents a severe anxiety spike.

Teach and practice an alternative coping strategy (e.g., deep breathing, guided imagery) before reducing the ritual. The client must have a replacement tool to manage the distress.

CautionNever forcibly stop the ritual or remove all triggers without consent. This constitutes flooding, which can cause panic, aggression, and rupture the therapeutic relationship.

## 핵심 개념

- **Obsessive-Compulsive Disorder** — An anxiety disorder characterized by obsessions and compulsions. The thoughts or behaviors are excessive and cause significant impairment in the individual's daily functioning.
- **Exposure and Response Prevention** — First-line treatment for obsessive-compulsive disorder. A cognitive behavioral therapy technique that gradually exposes the patient to anxiety-provoking situations (exposure) while training them to refrain from performing compulsive behaviors (response) that neutralize the anxiety (prevention).
- **Compulsion** — Repetitive behaviors (e.g., hand washing, checking) or mental acts (e.g., counting, silent recitation) performed to reduce or prevent anxiety triggered by obsessive thoughts. Provides only temporary relief.
- **Anxiety** — Core emotion of obsessive-compulsive disorder. The intense discomfort, worry, or fear felt when obsessive thoughts occur, which drives the performance of compulsive behaviors.
- **Coping Strategies** — Healthy ways to cope with anxiety or stress. In OCD treatment, deep breathing, relaxation training, and cognitive restructuring are taught as alternatives to replace compulsive behaviors.

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