A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking.
Which action should the nurse implement?
Postpone the client interview until the next day.
Document the client's paranoid behavior.
Attempt to ask the client simple questions.
Ask another nurse to talk with the client.
The Correct Answer is C
Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.
Correct Answer is B
Explanation
Choice A rationale:
Vomiting, seizures, and loss of consciousness are more severe symptoms that are not typically associated with narcotic withdrawal but could indicate other medical issues.
Choice B rationale:
Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal. These symptoms are commonly associated with opioid withdrawal, especially when there are needle marks on the client's arms, which may suggest a history of opioid use. Opioid withdrawal symptoms can include restlessness, sweating, and gastrointestinal discomfort, such as abdominal cramps. Therefore, these findings should be documented and reported for further assessment and appropriate intervention related to narcotic withdrawal.
Choice C rationale:
Depression, fatigue, and dizziness are not specific to narcotic withdrawal and could be related to various conditions.
Choice D rationale:
Hypotension, shallow respirations, and dilated pupils may suggest opioid overdose rather than withdrawal.
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