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 D
Explanation
- A: Providing a list of alternative activities may reduce fatigue, but it does not consider the child's interest in swimming, which can be therapeutic and enjoyable for children with Duchenne muscular dystrophy.
- B: While team sports can be good for socialization, they may not be suitable for a child with Duchenne muscular dystrophy due to the progressive muscle weakness associated with the condition, which could lead to increased risk of injury.
- C: At the age of 6, children are capable of understanding basic risks, and it is important to communicate with them appropriately rather than assuming they are too young. Moreover, swimming can be adapted to be safe for children with physical limitations.
- D: Swimming is an excellent activity for children with Duchenne muscular dystrophy because it is low-impact and can help maintain muscle strength and function. With proper supervision and precautions, the risks can be managed, making it a suitable activity for the child to continue.
Correct Answer is B
Explanation
A. Initiating teaching for client care after discharge is incorrect. Teaching, especially initial or comprehensive education, is within the scope of practice of a registered nurse (RN), not a practical nurse (PN).
B. Using bladder ultrasound to detect urinary retention is correct. This is a task within the scope of practice for a PN, as it involves data collection and does not require independent clinical judgment.
C. Completing comprehensive assessments is incorrect. Comprehensive assessments require critical thinking and are the responsibility of the RN. PNs may collect data but do not perform initial comprehensive assessments.
D. Beginning initial sterile wound care for surgical clients is incorrect. The RN should perform the first sterile dressing change postoperatively to assess the wound properly. The PN may perform subsequent dressing changes per facility policy.
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