While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?
Leave the client's room so she can act out her anxiety.
State it is unacceptable to undress during the interview.
Ignore the client's inappropriate behavior.
Change to less anxiety-provoking questions.
The Correct Answer is B
A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale for A: Redressing the abdominal incision is crucial as the dressing is no longer occlusive, which could lead to infection. An intact dressing also prevents the client from picking at the site, which could cause further harm or delay healing.
Rationale for B: Leaving the lights on might help with visual perception for a client with dementia, but it does not directly address the immediate risk of infection or the client's interference with the dressing.
Rationale for C: Applying restraints could be considered for a client who is at risk of harming themselves, but this should be a last resort after other interventions have been tried due to the potential for physical and psychological harm.
Rationale for D: Replacing the IV site with a smaller gauge is not indicated by the pink insertion site alone and does not address the client's confusion or behavior towards the dressing.
Correct Answer is A
Explanation
A. The neck is the correct location for auscultating a carotid bruit. A carotid bruit is an abnormal sound heard over the carotid artery in the neck, typically indicative of turbulent blood flow due to a narrowing or blockage in the artery.
B. Auscultating the femoral region would not yield information about carotid bruits. The femoral region pertains to the upper thigh area and is not anatomically related to the carotid artery.
C. The cubital fossa is the inner elbow region and is not associated with auscultation for carotid bruits. It is typically used for auscultation of blood pressure using the brachial artery.
D. The navel (belly button) is not a relevant location for auscultation for carotid bruits. It is far from the carotid arteries and would not provide any meaningful information about carotid artery sounds.
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