A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?

Assist the client to use new coping strategies.

Establish confidentiality guidelines with the client.

Help the client to make behavioral changes.

Share information with the client about their disorder.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assisting the client to use new coping strategies is an important part of managing bipolar disorder, but it is not the first action a nurse should take when establishing a nurse-client relationship. Coping strategies will be more effective once a trusting relationship has been established and the client feels secure in sharing personal information.

Choice B reason: Establishing confidentiality guidelines with the client is the first and most crucial step in forming a therapeutic nurse-client relationship. It sets the foundation for trust and openness, ensuring the client understands that their personal information will be protected and shared only with those directly involved in their care.

Choice C reason: Helping the client to make behavioral changes is a goal in the treatment of bipolar disorder. However, before any interventions can be planned or implemented, the nurse must first establish a rapport and trust with the client, which begins with ensuring confidentiality.

Choice D reason: Sharing information with the client about their disorder is essential for their understanding and participation in care. However, this should occur after establishing a relationship in which the client feels comfortable and secure, knowing their privacy is respected.

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Correct Answer is B

Explanation

Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.

A. Witness an informed consent for a client who is scheduled for electroconvulsive therapy. B. Explain the benefits of light therapy to a client who has depressive disorder. C. Discuss the adverse effects of antianxiety medications with a client who has an anxiety disorder. D. Participate in solitary activities with a client who has mania.

Correct Answer is D

Explanation

Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.

Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.

Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.

Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.

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A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is B

Explanation

A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

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A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?

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