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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Digoxin.
Digoxin is a cardiac glycoside that helps increase the force of myocardial contraction and is generally used to treat heart failure. It does not typically pose a significant risk for cardiogenic shock.

B. Hydrochlorothiazide.
Hydrochlorothiazide is a diuretic used to manage fluid retention in heart failure. It can cause electrolyte imbalances but is not directly linked to causing cardiogenic shock.

C. Nadolol.
Nadolol is a beta-blocker, which can reduce the heart rate and the strength of heart contractions. In a client with severe heart failure, excessive beta-blockade can lead to a significant decrease in cardiac output, increasing the risk for cardiogenic shock.

D. Captopril.
Captopril is an ACE inhibitor that helps manage heart failure by reducing afterload and preload.
While it can cause hypotension, it is not typically associated with a direct risk of cardiogenic shock.

A. The client may be developing sepsis. B. The client may be dehydrated. C. The client may have increasing symptoms of head injury. D. The client may have been sleeping. E. The client may be improving clinically. F. The client may require more morphine G. The client may be experiencing sedative effects of morphine.

Correct Answer is ["C","D","G"]

Explanation

A. The client may be developing sepsis.

Sepsis typically presents with symptoms such as fever, increased heart rate, increased respiratory rate, and altered blood pressure. There is no indication of these signs in the provided data,
making sepsis an unlikely cause for the change in the Glasgow Coma Scale (GCS) score.

B. The client may be dehydrated.

Dehydration can affect cognitive function, but there is no evidence suggesting dehydration in this scenario (e.g., normal heart rate, blood pressure, and no noted intake/output imbalance).
C. The client may have increasing symptoms of head injury.

A decrease in GCS score can indicate worsening head injury symptoms, such as increased intracranial pressure or bleeding.
D. The client may have been sleeping.

Sleeping can temporarily affect the GCS score, particularly the eye-opening component.

E. The client may be improving clinically.

Improvement clinically would likely result in a stable or improved GCS score, not a decrease.

F. The client may require more morphine.

Needing more morphine would typically be due to increased pain, but this should not directly affect the GCS score unless severe pain is causing altered consciousness, which is not indicated here.
G. The client may be experiencing sedative effects of morphine.

Morphine, especially given intravenously, can cause sedation, which could lower the GCS score.

H. The client may need food.

Needing food would not typically cause an immediate change in GCS score unless associated with severe hypoglycemia, which is not indicated by the provided data.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

Correct Answer is C

Explanation

Exhibits Which may have caused the change in the Glasgow Coma Scale score between 2000 and 2400? Select all that apply.

Correct Answer is ["C","D","G"]

Explanation

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