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 B

Explanation

Choice A rationale
While the patient’s currently prescribed medications are important information, they are not the most immediate concern in this situation. The healthcare provider will need this information, but it does not need to be the first piece of information provided.

Choice B rationale
The increasing confusion of the patient is the most immediate concern and should be communicated first. Confusion and disorientation can be signs of a serious condition such as a brain injury, especially following a fall. It is crucial to relay this information to the healthcare provider as soon as possible so that appropriate diagnostic tests can be ordered and treatment can be initiated.
Choice C rationale
The patient’s healthcare power of attorney is important information, especially if the patient’s condition worsens and they are unable to make decisions for themselves. However, this information does not need to be communicated first. The immediate concern is the patient’s medical condition.
Choice D rationale
The fall from a ladder is certainly important information as it provides context for the patient’s current condition. However, it does not need to be the first piece of information provided. The healthcare provider will likely infer that a fall has occurred based on the other information provided (e.g., confusion, potential loss of consciousness).

A. Use a cushion when sitting. B. Offer a high protein diet. C. Provide only distilled water. D. Document abdominal girth.

Correct Answer is D

Explanation

Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.

Choice B rationale
Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.

Choice C rationale

Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.

Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse identifies an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours in a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is D

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?