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 ["0.8"]
Explanation
- Convert the client's weight from pounds to kilograms (kg).
- Calculate the enoxaparin sodium dosage per day based on the client's weight and the prescribed dosage of 1.5 mg/kg/day.
- Divide the enoxaparin sodium dosage by the concentration of the medication in the prefilled syringe (120 mg/0.8 mL) to determine the volume to administer.
Step 1: Convert weight from pounds to kilograms
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- Client's weight in kg = Client's weight in pounds / 2.2
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- Client's weight in kg = 176 pounds / 2.2 = 80 kg
Step 2: Calculate enoxaparin sodium dosage per day
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- Enoxaparin sodium dosage (mg/day) = Client's weight (kg) × Prescribed dosage (mg/kg/day)
- Enoxaparin sodium dosage (mg/day) = 80 kg × 1.5 mg/kg/day = 120 mg/day
Step 3: Determine the volume to administer
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- Volume to administer (mL) = Enoxaparin sodium dosage (mg/day) / Medication concentration (mg/mL)
- Volume to administer (mL) = 120 mg/day / (120 mg/0.8 mL) = 0.8 mL
Therefore, the nurse should administer 0.8 mL of enoxaparin sodium to the client.
Correct Answer is D
Explanation
A. Begin abdominal girth measurements.
Abdominal girth measurements may be important for assessing fluid status in clients with liver disease and ascites, but in this case, the elevated polymorphonuclear leukocyte count indicates a possible infection, requiring immediate intervention.
B. Review serum protein levels.
While monitoring serum protein levels is important in clients with liver disease, the priority in this situation is to address the potential infection indicated by the elevated leukocyte count.
C. Assess neurological status.
Neurological assessment may be relevant in some cases, but it is not the priority in a client with suspected infection after a paracentesis.
D. Initiate antibiotic therapy.
Given the client's symptoms and the elevated polymorphonuclear leukocyte count in the ascitic fluid, indicating possible infection (spontaneous bacterial peritonitis), initiating antibiotic therapy is the priority action to address the infection and prevent further complications.
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