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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While the patient’s currently prescribed medications are important information, they are not the most immediate concern in this situation. The healthcare provider will need this information, but it does not need to be the first piece of information provided.
Choice B rationale
The increasing confusion of the patient is the most immediate concern and should be communicated first. Confusion and disorientation can be signs of a serious condition such as a brain injury, especially following a fall. It is crucial to relay this information to the healthcare provider as soon as possible so that appropriate diagnostic tests can be ordered and treatment can be initiated.
Choice C rationale
The patient’s healthcare power of attorney is important information, especially if the patient’s condition worsens and they are unable to make decisions for themselves. However, this information does not need to be communicated first. The immediate concern is the patient’s medical condition.
Choice D rationale
The fall from a ladder is certainly important information as it provides context for the patient’s current condition. However, it does not need to be the first piece of information provided. The healthcare provider will likely infer that a fall has occurred based on the other information provided (e.g., confusion, potential loss of consciousness).
Correct Answer is D
Explanation
Choice A rationale
While having a case management evaluation of the client’s home environment can provide valuable information and potential solutions for caregiving challenges, it does not directly address the caregiver’s immediate need for relief and support.
Choice B rationale
Hiring a private duty nurse could provide the caregiver with some time away from caregiving duties. However, this may not be a feasible option for many caregivers due to the cost associated with private nursing care.
Choice C rationale
Proposing that extended family could return to the area to help provide assistance assumes that such help is available and willing. This may not be the case for many caregivers.
Choice D rationale
Suggesting that social services be contacted to find a respite care facility for the client directly addresses the caregiver’s need for relief and support. Respite care provides temporary relief for primary caregivers, allowing them to rest and take care of their own needs. This can help to alleviate symptoms of caregiver burnout, such as poor sleep and frequent crying.
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