While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

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

State it is unacceptable to undress during the interview.

Ignore the client's inappropriate behavior.

Change to less anxiety-provoking questions.

Answer and Explanation

The Correct Answer is B

A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.

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Correct Answer is D

Explanation

A. "How do you cope with the voices?" is an important question to assess the client's coping mechanisms, but it does not provide direct information about the content or nature of the auditory hallucinations. While coping strategies are relevant, understanding the nature of the hallucinations is crucial for treatment planning.

B. "When do you hear voices?" is important to understand the timing and frequency of the hallucinations, but it does not provide information about the content or nature of the hallucinations themselves.

C. "Which medication works best?" is important to assess the client's previous treatment history and response to medication, but it does not directly address the current assessment of the auditory hallucinations.

D. "What are the voices saying?" is the most important question because it directly addresses the content and nature of the auditory hallucinations. Understanding the specific content, tone, and perceived significance of the voices can provide valuable information for diagnosis, treatment planning, and assessing the client's level of distress or impairment.

A. Measure and record the client's urinary output every day. B. Obtain a blood pressure reading before the client gets out of bed. C. Obtain the client's vital signs every 4 hours when awake. D. Provide the client with teaching regarding a cardiac diet.

Correct Answer is B

Explanation

A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.

B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.

C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.

D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.

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While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the nurse to include in the assessment of this client?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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