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 C
Explanation
Choice A rationale
While avoiding exposure to large crowds can help prevent infections, especially for patients with compromised immune systems, it is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Choice B rationale
While emotional support is important for patients dealing with health issues, calling a crisis hotline if feeling lonely is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Choice C rationale
This is the most crucial information for the patient. Acetaminophen is found in many over-the- counter medications, and further intake could exacerbate liver damage.
Choice D rationale
While a balanced diet is important for overall health, following a high carbohydrate, low fat, low protein diet is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Correct Answer is ["D","E","F"]
Explanation
Choice A rationale
While it’s important to honor commitments, it’s also crucial to recognize when the caregiving role becomes too stressful or burdensome. Insisting on keeping a promise despite significant stress can lead to caregiver burnout.
Choice B rationale
This statement is not accurate. Moving a loved one into a care facility is sometimes the best decision for both the caregiver and the care recipient. It does not reflect a lack of love, but rather a recognition of the need for professional help.
Choice C rationale
This statement is not accurate. Caring for an adult, especially one with health issues, can be more challenging than raising a child in many ways.
Choice D rationale
Involving the care recipient in the decision-making process can help maintain their autonomy and dignity. It can also make the caregiving process more manageable.
Choice E rationale
It’s normal to have mixed feelings about a loved one for whom you’re providing care. Acknowledging these feelings can be an important step in managing caregiver stress.
Choice F rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
Choice G rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
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