# Situation: A 34-year-old woman is admitted to the psychiatric unit with obsessive-compulsive disorder (OCD). She washes her hands for 3 to 4 hours a day because she fears contamination, and the skin of her hands is cracked and red. Her physical examination and electrocardiogram (ECG) on admission were normal. On her first morning she is still washing her hands when breakfast is served, and she misses the meal. What should the nurse do for the coming mornings?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630181  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 34-year-old woman is admitted to the psychiatric unit with obsessive-compulsive disorder (OCD). She washes her hands for 3 to 4 hours a day because she fears contamination, and the skin of her hands is cracked and red. Her physical examination and electrocardiogram (ECG) on admission were normal.

On her first morning she is still washing her hands when breakfast is served, and she misses the meal. What should the nurse do for the coming mornings?

## 보기

1. Wake her earlier so washing ends before breakfast **✔ 정답**
2. Tell her she will miss meals if she keeps washing
3. Lock the bathroom until breakfast is over
4. Remind her each time that her hands are already clean

**정답: 1**

## 해설

Early in care, rituals are not blocked abruptly, because stopping them causes severe anxiety. The nurse allows time for the ritual within a structured schedule, such as waking the client earlier, and the rituals are limited gradually later, as agreed in the treatment plan.

## 심화 해설

Core clinical principle

In the early phase of OCD treatment, the nurse does not abruptly block a compulsive ritual. Compulsions function to neutralize the intense anxiety generated by obsessions, and removing that safety behavior too quickly can trigger overwhelming distress and even panic. The immediate nursing goal is not to eliminate the ritual, but to contain it within a structured daily schedule so that basic needs such as nutrition are still met. Waking the client earlier creates a planned window in which the handwashing can occur without displacing breakfast.

Watch out! Options that threaten meal removal, lock the bathroom, or repeatedly challenge the client's belief are confrontational and premature at this stage. They increase anxiety and damage the therapeutic alliance.

Why early structure matters

OCD is characterized by intrusive, distressing obsessions and repetitive compulsions performed to reduce the anxiety those obsessions produce [1]. The compulsion is maintained by negative reinforcement: the temporary relief from anxiety strengthens the behavior. Because the ritual serves a real anxiety-regulating function for the client, removing it before alternative coping skills are established leaves the client without any way to manage the distress.

In the first days of hospitalization, the treatment team typically allows the ritual to continue within limits. The nurse collaborates with the client to schedule the ritual, which preserves predictability and control. Gradual limitation of the ritual is introduced later, once the client has agreed to the plan and has begun learning alternative anxiety-management strategies [1].

Clinical reasoning for each option

| Option | Rationale | Appropriateness |
| --- | --- | --- |
| 1 Wake her earlier so washing ends before breakfast | Allows the ritual within a structured schedule; preserves nutrition and reduces conflict | Correct: early care focuses on scheduling, not blocking |
| 2 Tell her she will miss meals if she keeps washing | Uses a threat or punishment; increases anxiety and does not teach coping | Inappropriate: confrontational and countertherapeutic |
| 3 Lock the bathroom until breakfast is over | Abruptly blocks the compulsion; can precipitate severe anxiety or panic | Inappropriate: premature and unsafe without alternative skills |
| 4 Remind her each time that her hands are already clean | Challenges the obsession with logic; OCD fears are ego-dystonic but not responsive to reassurance | Inappropriate: reassurance does not reduce the compulsion and may reinforce the cycle |

Why reassurance does not work

A common misconception is that telling the client her hands are clean will reduce the washing. In OCD, the obsession is not a simple lack of information. The client often recognizes that the fear is excessive or irrational, yet the anxiety remains [1]. Repeated reassurance can become part of the ritual itself, temporarily soothing the anxiety but strengthening the need for further reassurance. Key point! The nurse should avoid engaging in reassurance or debating the content of the obsession.

Nursing application in the first days

The priority is to maintain physiological stability while building trust. Missing meals leads to inadequate nutrition, which worsens fatigue, irritability, and overall coping capacity. By waking the client earlier, the nurse communicates that the ritual is acknowledged and accommodated for now, which reduces power struggles. This approach also allows the nurse to observe the ritual's duration and triggers, information that is essential for the later gradual exposure and response prevention plan [1].

The skin breakdown on the hands is a separate but related concern. Cracked, red skin from prolonged washing requires skin care interventions, but those are addressed alongside the scheduling strategy, not by forcing the client to stop washing immediately. The normal physical examination and ECG on admission rule out acute medical instability, so the nursing focus remains on the behavioral and nutritional management described.

Early OCD nursing care is about structuring the ritual, not eliminating it. The ritual is reduced gradually only after the client has developed alternative coping skills and agreed to the treatment plan [1].References (research sources)

- [1]Obsessive compulsive disorder: overview of the condition and its nursing management.Research articleWagstaff C (2024) · DOI: 10.7748/ns.2024.e12269

## 임상 시나리오

Early OCD Ritual ManagementSchedule the compulsion, do not block it
In the early phase of OCD treatment, the nurse should not abruptly block a compulsive ritual. Compulsions neutralize the intense anxiety from obsessions, and removing that safety behavior too quickly can trigger overwhelming distress or panic.

The immediate goal is to contain the ritual within a structured daily schedule so basic needs such as nutrition are still met. Waking the client earlier creates a planned window for handwashing without displacing breakfast.

CautionThreatening meal removal, locking the bathroom, or repeatedly challenging the client's belief are confrontational and premature. These actions increase anxiety and damage the therapeutic alliance.

## 핵심 개념

- **Obsessive-compulsive disorder (OCD)** — A disorder characterized by intrusive, distressing obsessions and repetitive compulsions performed to reduce the anxiety those obsessions produce.
- **Compulsion** — A repetitive behavior or mental act performed to neutralize the anxiety generated by an obsession, maintained by negative reinforcement.
- **Negative reinforcement** — A process in which temporary relief from anxiety strengthens the compulsive behavior, making it more likely to recur.
- **Therapeutic alliance** — The collaborative, trusting relationship between nurse and client that supports treatment engagement and is easily damaged by confrontational approaches.
- **Structured schedule** — A planned daily routine that allows time for rituals within limits so basic needs such as nutrition are still met.

## 같은 주제 문제

- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629966)
- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629967)
- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629968)
- [Situation: A 38-year-old woman with bipolar I disorder is admitted to the psychiatric ward…](https://mymerci.kr/pages/nclex_q.php?qn_id=629969)
- [Situation: The nurse in a community mental health program leads a psychoeducation session …](https://mymerci.kr/pages/nclex_q.php?qn_id=629970)
- [Situation: The nurse in a community mental health program leads a psychoeducation session …](https://mymerci.kr/pages/nclex_q.php?qn_id=629971)
- [Situation: The nurse in a community mental health program leads a psychoeducation session …](https://mymerci.kr/pages/nclex_q.php?qn_id=629972)
- [Situation: A 29-year-old factory worker is admitted to the psychiatric unit of a general h…](https://mymerci.kr/pages/nclex_q.php?qn_id=629973)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._