While conducting an admission assessment of a female client with bipolar disorder, the client suddenly starts to undress and throw her clothes around the room.
What should be the nurse’s initial action?
Switch to less anxiety-provoking Questions.
Ignore the client’s inappropriate behavior.
Leave the client’s room so she can act out her anxiety.
State that it is unacceptable to undress during the interview.
The Correct Answer is D
Choice A rationale
While switching to less anxiety-provoking questions might help in some situations, it does not address the immediate issue of the client undressing inappropriately.
Choice B rationale
Ignoring the client’s inappropriate behavior could potentially encourage further inappropriate actions and does not respect the therapeutic boundaries necessary in a nurse-client relationship.
Choice C rationale
Leaving the client’s room might escalate the situation further and does not address the immediate issue.
Choice D rationale
The nurse should assertively but respectfully communicate that undressing is not appropriate during the interview. This sets clear boundaries and expectations for the client’s behavior.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Pregabalin is a medication used to treat nerve pain, particularly in conditions like diabetic peripheral neuropathy. A reduced level of pain would indicate that the medication is effective.
Choice B rationale
Improved visual acuity is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect vision.
Choice C rationale
Full volume of pedal pulses is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect circulation.
Choice D rationale
Granulating tissue in a foot ulcer is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect wound healing.
Correct Answer is A
Explanation
Choice A rationale
Initiating a hearing and vision screening program for first graders is an example of secondary prevention. Secondary prevention aims to identify and treat an illness or disease at an early stage, which is exactly what a screening program does.
Choice B rationale
Observing a person with type I diabetes mellitus self-administer a dose of insulin is not an example of secondary prevention. This is more related to disease management, which falls under tertiary prevention.
Choice C rationale
Preparing a presentation on how to prevent the spread of lice is an example of primary prevention, which aims to prevent disease or injury before it ever occurs.
Choice D rationale
Collaborating with a science teacher to prepare a health lesson could be seen as primary prevention if the lesson is about preventing disease, or tertiary prevention if it’s about managing existing conditions.
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