A nurse in an inpatient mental health facility is reviewing the medical record of a client who has bipolar disorder. When planning to establish a nurse-client relationship with the client, which of the following actions should the nurse plan to take first?
Assist the client to use new coping strategies.
Establish confidentiality guidelines with the client.
Help the client to make behavioral changes.
Share information with the client about their disorder.
The Correct Answer is B
Choice A reason: Assisting the client to use new coping strategies is an important part of managing bipolar disorder, but it is not the first action a nurse should take when establishing a nurse-client relationship. Coping strategies will be more effective once a trusting relationship has been established and the client feels secure in sharing personal information.
Choice B reason: Establishing confidentiality guidelines with the client is the first and most crucial step in forming a therapeutic nurse-client relationship. It sets the foundation for trust and openness, ensuring the client understands that their personal information will be protected and shared only with those directly involved in their care.
Choice C reason: Helping the client to make behavioral changes is a goal in the treatment of bipolar disorder. However, before any interventions can be planned or implemented, the nurse must first establish a rapport and trust with the client, which begins with ensuring confidentiality.
Choice D reason: Sharing information with the client about their disorder is essential for their understanding and participation in care. However, this should occur after establishing a relationship in which the client feels comfortable and secure, knowing their privacy is respected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.
Choice A reason:
Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.
Choice B reason:
Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.
Choice C reason:
Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.
Choice D reason:
Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.
Correct Answer is A
Explanation
Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.
Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.
Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.
Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.
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