A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first?
Inform the client that this admission is confidential.
Determine coping strategies that the client has used in the past.
Assist the client in facilitating a change in behavior.
Introduce the client to other clients in the day room.
The Correct Answer is A
Choice A reason: Informing the client that the admission is confidential is the first priority. Establishing trust and ensuring the client feels safe is essential before proceeding with further assessment or interventions. Confidentiality reassures the client that sensitive information will be protected, which is critical for someone who is fearful and withdrawn.
Choice B reason: Determining coping strategies is important but should occur after trust is established. A fearful client may not disclose coping mechanisms until they feel secure in the therapeutic relationship.
Choice C reason: Assisting the client in facilitating a change in behavior is premature during admission. The nurse must first assess and build rapport before initiating behavioral interventions.
Choice D reason: Introducing the client to others in the day room may increase anxiety. A fearful and withdrawn client may feel overwhelmed by social interaction before trust and safety are established.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Allowing the client to eat in their room is not appropriate because clients with anorexia nervosa often isolate themselves and may attempt to avoid eating or hide food. Supervised meals in a communal or monitored setting are necessary to ensure adequate intake and prevent food avoidance behaviors.
Choice B reason: Obtaining vital signs only once per day is insufficient. Clients with anorexia nervosa are at risk for severe complications such as bradycardia, hypotension, hypothermia, and electrolyte imbalances. Frequent monitoring is required to detect early signs of medical instability. Once daily vital signs would miss important changes.
Choice C reason: Weighing the client daily after the first voiding is the correct intervention. This ensures consistency and accuracy in monitoring weight trends, as voiding eliminates the variable of bladder volume. Daily weights are essential for tracking progress, evaluating treatment effectiveness, and identifying rapid changes that may indicate medical risk.
Choice D reason: Allowing the client to determine their daily calorie intake is inappropriate because individuals with anorexia nervosa often severely restrict calories. Nutritional intake must be carefully planned and supervised by the healthcare team to promote gradual weight restoration and prevent refeeding syndrome.
Correct Answer is D
Explanation
Choice A reason: Specific body postures are associated with practices like yoga or tai chi, not biofeedback.
Choice B reason: Improving range of motion is linked to physical therapy or exercise interventions, not biofeedback.
Choice C reason: Concentrating on soothing images is a relaxation technique such as guided imagery, not biofeedback.
Choice D reason: Biofeedback therapy teaches clients to recognize and control physiological responses such as blood pressure, heart rate, and muscle tension. This statement correctly reflects the purpose of biofeedback.
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