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.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Lack of empathy is not a characteristic finding in OCPD. While individuals with OCPD may appear insensitive or less responsive to the needs and feelings of others due to their focus on rules and productivity, this does not equate to a true lack of empathy.
Choice B reason: Preoccupation with details is a hallmark of OCPD. Individuals with this disorder have an excessive concern with orderliness, perfectionism, and control over their environment and tasks. They may become so involved in making every detail perfect that it can hinder task completion and efficiency.
Choice C reason: Exploitative behavior is more characteristic of other personality disorders, such as narcissistic personality disorder, and is not a typical feature of OCPD. People with OCPD are more likely to be overly conscientious and fair in their dealings with others.
Choice D reason: Excessive clinging is not typically associated with OCPD. Instead, individuals with OCPD may have difficulty delegating tasks or working with others unless things are done precisely their way, which stems from their need for control rather than a need for closeness or reassurance.
Correct Answer is C
Explanation
Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.
Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.
Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.
Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.
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