A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

Sharing personal information can blur the professional boundaries and might not be effective in reducing the client's suspicion. It's important to maintain a professional demeanor while building trust.

B) Approach the client frequently throughout the day for brief interactions:

While it's important to establish a presence and provide support, approaching the client too frequently might increase their discomfort and reinforce their suspicion. It's better to allow the client some personal space while ensuring they know you are available when needed.

C) Adopt a neutral attitude when providing care.

Explanation:

When dealing with a client who is extremely suspicious, it's important for the nurse to approach the situation with a neutral attitude. A neutral attitude helps to build trust and minimize any potential triggers for the client's suspicion. This approach creates a non-threatening environment where the client may feel more comfortable and gradually begin to open up.

D) Wait for the client to initiate interaction:

While giving the client space is important, waiting for them to initiate interaction might prolong the development of a therapeutic relationship. Clients who are extremely suspicious might have difficulty initiating interactions due to their concerns.