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: An altered level of consciousness is not typically associated with Alzheimer's disease. Patients with Alzheimer's may experience confusion or disorientation, but changes in consciousness, such as stupor or coma, are not characteristic symptoms of the disease.

Choice B reason: Failure to recognize familiar objects, known as agnosia, is a common finding in Alzheimer's disease. As the disease progresses, the ability to recognize objects, faces, and even sounds can be impaired, which is a direct result of the deterioration of brain areas involved in processing sensory information.

Choice C reason: Excessive motor activity is not a common finding in Alzheimer's disease. While patients may experience restlessness, the disease often leads to a decrease in overall activity levels due to cognitive decline and the eventual difficulty with coordination and motor functions.

Choice D reason: Rapid mood swings can occur in Alzheimer's disease, but they are not as prominent as other cognitive symptoms. Mood changes in Alzheimer's are usually a result of the frustration and confusion experienced by the patient rather than a direct symptom of the disease itself.

A. Blood glucose 256 mg/dL (74 to 106 mg/dL) B. WBC count 6,000/mm³ (5,000 to 10,000/mm³) C. Platelets 250,000/mm³ (150,000 to 400,000/mm³) D. Sodium 140 mEq/L (136 to 145 mEq/L)

Correct Answer is A

Explanation

Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.

Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.

Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.

Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.

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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

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is reviewing laboratory results of a client who has schizophrenia and is taking risperidone. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

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