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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"C,B"},"C":{"answers":"B"}}

Explanation

Choice A rationale

Chronic alcoholism is often associated with both Vitamin B12 and Folic acid deficiency anemia. Alcohol interferes with the absorption of these vitamins in the gut, leading to their deficiency.

Choice B rationale

Malabsorption syndrome can lead to Iron deficiency anemia, Vitamin B12 deficiency anemia, and Folic acid deficiency anemia. In malabsorption syndrome, the small intestine can’t absorb enough of certain nutrients and fluids.

Choice C rationale

Dietary deficiency can result in Iron deficiency anemia, Vitamin B12 deficiency anemia, and Folic acid deficiency anemia. These types of anemia can occur when the body doesn’t have enough of the vitamins needed to produce enough healthy red blood cells.

A. Monitor capillary refill distal to the infusion site. B. Apply a topical anesthetic at the infusion site for burning. C. Assess IV site frequently for signs of extravasation. D. Explain that temporary burning at the IV site may occur.

Correct Answer is C

Explanation

Choice A rationale

Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.

Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.

Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.

Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"C,B"},"C":{"answers":"B"}}

Explanation

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

Correct Answer is C

Explanation

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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?