While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?

Switch to less anxiety-provoking Questions.

Ignore the client’s inappropriate behavior.

Leave the client’s room so she can act out her anxiety.

State that it is unacceptable to undress during the interview.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While switching to less anxiety-provoking questions might help in some situations, it does not address the immediate issue of the client undressing inappropriately.
Choice B rationale
Ignoring the client’s inappropriate behavior could potentially encourage further inappropriate actions and does not respect the therapeutic boundaries necessary in a nurse-client relationship.
Choice C rationale
Leaving the client’s room might escalate the situation further and does not address the immediate issue.
Choice D rationale
The nurse should assertively but respectfully communicate that undressing is not appropriate during the interview. This sets clear boundaries and expectations for the client’s behavior.

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.

Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.

A. Initiate seizure precautions. B. Assess pupillary response to light hourly. C. Measure urinary output every hour. D. Monitor serum potassium frequently.

Correct Answer is C

Explanation

Choice A rationale

While seizure precautions are important for clients receiving certain medications or with certain conditions, they are not typically necessary for clients receiving dopamine. Dopamine, an adrenergic agonist, does not typically increase the risk of seizures.

Choice B rationale

Assessing pupillary response to light hourly is not typically necessary for clients receiving dopamine. Dopamine does not typically affect pupillary response.

Choice C rationale

Measuring urinary output every hour is an important intervention for a client receiving dopamine. Dopamine at low to moderate doses can dilate renal blood vessels, which can increase urine output. Therefore, monitoring urinary output can help assess the effectiveness of the medication and the client’s renal perfusion.

Choice D rationale

While it is important to monitor electrolyte levels in clients receiving certain medications, frequent monitoring of serum potassium is not typically necessary for clients receiving dopamine. Dopamine does not typically affect serum potassium levels.

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While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room. What should be the nurse’s initial action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is C

Explanation

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While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?