A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
Explanation & Rationale
A. Document the client's paranoid behavior: While documentation is important, it does not actively engage the client or promote therapeutic rapport. Simply recording the behavior does not address the immediate need to establish communication or trust during the assessment. B. Ask another nurse to talk with the client: Switching interviewers may not overcome the client’s suspicion and can sometimes increase mistrust. Consistency in staff and approach is more effective for building rapport with a guarded client. C. Postpone the client interview until the next day: Delaying the assessment may prolong anxiety and prevent timely identification of needs or safety concerns. Engaging the client as soon as possible helps establish trust and ensures prompt care planning. D. Attempt to ask the client simple questions: Using brief, clear, and nonthreatening questions helps the client feel safer and reduces perceived threat. Simple questions allow gradual engagement, encourage participation in the assessment, and promote the development of therapeutic rapport while respecting the client’s guarded and suspicious state.