Choice A reason: Veracity refers to truthfulness, such as providing accurate information about medications to the client. Supporting a refusal doesn’t inherently involve honesty or disclosure; it’s about respecting a decision. In this case, the nurse isn’t focusing on truth-telling but on honoring the client’s choice. Veracity applies to communication, not decision-making rights, so it doesn’t fit the nurse’s action of supporting the client’s refusal here.

Choice B reason: Autonomy is the ethical principle of respecting a client’s right to make their own decisions, including refusing treatment, if competent. By supporting the client’s refusal, the nurse upholds this self-determination, a cornerstone of patient-centered care. In bipolar disorder, unless the client poses an immediate danger, autonomy prevails. This action directly reflects the nurse prioritizing the client’s personal agency over forcing medication.

Choice C reason: Beneficence involves acting in the client’s best interest, often by encouraging treatment like medications to manage bipolar symptoms. Supporting refusal contradicts this, as it may not promote well-being in a clinical sense. The nurse’s action prioritizes choice over potential benefit, so beneficence isn’t the principle displayed here, despite its relevance to overall care goals.

Choice D reason: Justice ensures fair treatment and resource allocation among clients, unrelated to supporting an individual’s medication refusal. This principle applies to equity in care delivery, not personal decisions about treatment. The nurse’s action focuses on one client’s rights, not fairness across a group, making justice an incorrect fit for this scenario.

Choice A reason: A no-harm contract relies on the client’s promise, but with an active suicide plan, this isn’t reliable or safe. Suicidal ideation with intent requires close monitoring, not negotiated privacy. This statement falsely suggests a verbal agreement overrides risk, undermining the priority of safety. It’s inappropriate given the severity of the client’s expressed plan.

Choice B reason: Linking observation to medication levels assumes pharmacology alone mitigates risk, ignoring immediate danger from a suicide plan. Therapeutic levels take time, irrelevant to acute safety needs. This statement dismisses current risk, focusing on a future state, and fails to address the client’s demand directly. It’s not the best response for this urgent situation.

Choice C reason: Suggesting the client’s cooperation with treatment justifies privacy ignores the active suicide risk. Following a plan doesn’t negate intent to harm, and deferring to the provider delays action. This statement misrepresents safety priorities, offering false hope of autonomy when constant observation is required, making it unsuitable.

Choice D reason: Expressing concern and emphasizing safety directly addresses the client’s risk with a clear, empathetic rationale for observation. It acknowledges their demand while prioritizing protection, aligning with mental health protocols for suicide risk. This response balances care with firmness, ensuring the client understands the need for oversight without negotiation.

Choice A reason: Electroconvulsive therapy (ECT) isn’t a primary treatment for borderline personality disorder, which relies on psychotherapy like DBT. ECT targets severe mood disorders, not personality traits like emotional instability. Improvement in BPD symptoms wouldn’t indicate ECT efficacy, as it’s not the intended outcome. This finding misaligns with ECT’s clinical purpose.

Choice B reason: Reduced seizure frequency relates to epilepsy management, not ECT, which induces controlled seizures to treat psychiatric conditions. Effectiveness isn’t measured by fewer spontaneous seizures but by mood improvement. This outcome reflects a misunderstanding of ECT’s mechanism, making it an incorrect indicator of success.

Choice C reason: ECT is primarily used for severe depression, especially when medications fail, by altering brain chemistry via induced seizures. Improvement in depressive symptoms—elevated mood, energy, or appetite—directly indicates efficacy, aligning with its therapeutic goal. This finding confirms ECT’s intended effect, making it the correct measure.

Choice D reason: Decreased fear of heights suggests phobia improvement, treated by exposure therapy, not ECT. ECT focuses on mood disorders, not specific anxiety conditions unrelated to depression. This outcome doesn’t reflect ECT’s purpose or mechanism, so it’s not a valid indicator of treatment success here.

Choice A reason: Suggesting a list of anger triggers encourages reflection, useful for long-term management, but doesn’t address immediate aggression’s safety risk. In a facility, current behavior toward others takes precedence over future coping strategies. This action delays assessing intent, potentially allowing harm to escalate, making it a lower priority in this acute scenario.

Choice B reason: Asking about intent to harm others directly assesses the client’s risk, the top priority in an aggressive situation. Safety is paramount in mental health settings, and this question identifies imminent danger, guiding de-escalation or restraint decisions. It aligns with ABC (airway, breathing, circulation) principles adapted to behavior, ensuring protection first.

Choice C reason: Role modeling healthy anger expression educates long-term coping but doesn’t mitigate current aggression’s threat to others. It’s a proactive strategy, not a reactive one, unsuitable when immediate safety is at stake. This action lacks urgency, postponing risk assessment, so it’s not the priority in this moment.

Choice D reason: Exploring stress reduction techniques aids overall mental health but isn’t urgent when aggression is active. It addresses underlying causes, not the immediate behavior endangering others. Safety supersedes stress management in a facility, making this a secondary intervention after risk is evaluated and controlled.

Choice A reason: Listening to voices encourages engagement with hallucinations, a schizophrenia symptom that worsens during relapse, contradicting prevention strategies. Teaching focuses on reality-based coping, like distraction or reporting symptoms, not amplifying delusions. This statement shows misunderstanding, risking escalation rather than control of the condition.

Choice B reason: Avoiding others during a suspected relapse isolates the client, potentially worsening symptoms by cutting support, a key relapse buffer. Social connection aids monitoring and intervention in schizophrenia. This reflects poor understanding, as prevention involves seeking help, not withdrawal, making it incorrect.

Choice C reason: Avoiding TV when hearing voices is a coping tactic but not a broad prevention strategy. It addresses a symptom reactively, not proactively, like recognizing early signs (e.g., sleep issues). Teaching emphasizes reporting triggers, not just avoidance, so this shows partial, not full, understanding.

Choice D reason: Reporting sleep trouble to a counselor reflects understanding that insomnia is an early relapse sign in schizophrenia, enabling timely intervention. Prevention teaching highlights recognizing and communicating prodromal symptoms to adjust treatment. This proactive step aligns with managing the condition effectively, indicating correct learning.

Choice A reason: Offering the medication later respects the client’s autonomy while maintaining treatment options, a standard approach unless immediate danger exists. Involuntary admission doesn’t automatically override refusal rights for non-emergent care like antianxiety meds. This action balances ethics and care, allowing reconsideration without force, aligning with least restrictive principles in mental health.

Choice B reason: Implementing consequences to coerce medication intake violates patient rights and ethical care standards. It assumes refusal warrants punishment, not education or negotiation, escalating tension. Involuntary status doesn’t justify behavioral manipulation for routine meds, making this punitive approach inappropriate and potentially harmful to trust.

Choice C reason: Informing the client he can’t refuse misrepresents rights; involuntary admission allows forced treatment only for imminent risk, not routine antianxiety medication. Patients retain autonomy unless legally deemed incompetent. This statement is legally inaccurate and coercive, undermining therapeutic rapport and ethical practice.

Choice D reason: Administering IM medication against refusal exceeds nursing scope without a specific order or emergency justification, like acute agitation. It violates autonomy and risks trauma, reserved for life-threatening situations, not routine refusal. This action is unethical and illegal without proper authorization in this context.

Choice A reason: Suggesting immediate grief counseling assumes the partner needs professional help without exploring their feelings, potentially dismissing their current emotional state. It’s directive rather than supportive, lacking empathy for the expressed guilt. This response skips validation, a key initial step, making it less therapeutic at this moment.

Choice B reason: Sharing personal grief normalizes the experience but shifts focus to the nurse, not the partner’s unique feelings of guilt. It risks minimizing their specific pain by generalizing it as part of grieving. This self-referential response lacks client-centeredness, reducing its effectiveness in addressing their concern.

Choice C reason: Acknowledging the difficulty of guilt validates the partner’s emotions, fostering a therapeutic connection without judgment. It invites further expression, aligning with active listening in grief support. This empathetic, open-ended response prioritizes their experience, making it the most appropriate and supportive choice here.

Choice D reason: Telling the partner not to feel guilty dismisses their emotions, implying their care was sufficient without evidence. It shuts down discussion, offering reassurance over exploration, which can feel invalidating. This directive response lacks sensitivity to their grief process, making it less suitable.

Choice A reason: Lethargy, muscle weakness, and blurred vision suggest lithium toxicity, requiring immediate blood levels to confirm (therapeutic range: 0.6-1.2 mEq/L). Toxicity risks escalate with dehydration or overdose, common in bipolar treatment. Drawing blood assesses severity, guiding urgent action like dose adjustment or cessation, prioritizing safety and making this the correct response.

Choice B reason: Assuring symptoms improve over time dismisses potential lithium toxicity, a serious risk needing evaluation, not patience. These signs don’t typically self-resolve without intervention, and delaying risks neurological or renal damage. This response ignores clinical urgency, endangering the client, so it’s inappropriate and unsafe.

Choice C reason: Decreasing sodium worsens lithium toxicity, as low sodium increases lithium retention by the kidneys, elevating levels. These symptoms indicate excess, not deficiency, needing assessment, not dietary change. This advice contradicts pharmacology, potentially harming the client further, making it incorrect.

Choice D reason: Continuing lithium as prescribed ignores toxicity signs—lethargy, weakness, vision changes—potentially leading to severe outcomes like seizures. Without blood levels, this risks progression, neglecting the need for immediate evaluation. It’s a dangerous response, bypassing critical assessment, so it’s not suitable.

Choice A reason: Keeping restraints on for a set minimum like 1 hour ignores the least restrictive principle, risking harm if the child calms sooner. Restraints require frequent reassessment, not arbitrary duration, to ensure safety and circulation. This rigid approach violates guidelines, making it unsafe and inappropriate.

Choice B reason: Monitoring vital signs every 15 minutes ensures the child’s safety in restraints, detecting distress, hypoxia, or injury from aggression or positioning. Conduct disorder doesn’t negate physiological risks, and standards mandate close observation. This action prioritizes well-being, aligning with protocol, making it the correct choice.

Choice C reason: Renewing restraint orders every 24 hours is standard but not immediate; it addresses future use, not current safety post-initiation. The priority is real-time monitoring, not administrative renewal. This action delays focus on the child’s acute state, so it’s not the top priority now.

Choice D reason: An in-person evaluation within 2 hours is ideal but secondary to immediate safety checks like vital signs. Regulations often allow 1-4 hours for provider review, depending on age, but monitoring precedes this. It’s important but not the first action, making it less urgent.

Choice A reason: Assistive personnel can engage in non-therapeutic, supportive tasks like solitary activities (e.g., puzzles) with a manic client, aiding distraction within their scope. This doesn’t require clinical judgment or education, fitting their role. It frees the nurse for skilled tasks, making it an appropriate delegation choice.

Choice B reason: Discussing medication adverse effects requires nursing knowledge of pharmacology and client response, beyond assistive personnel’s training. It involves assessment and education, reserved for licensed staff. Delegating this risks misinformation and safety, so it’s outside their scope and incorrect.

Choice C reason: Witnessing informed consent demands understanding legal and clinical implications, a nursing responsibility, not assistive personnel’s role. They lack authority to verify comprehension or voluntariness. This task can’t be delegated, as it’s a professional duty, making it unsuitable here.

Choice D reason: Explaining light therapy benefits involves teaching about treatment effects, requiring nursing expertise in depression management. Assistive personnel aren’t trained for such education, risking inaccurate delivery. This remains a nurse’s role, not delegable, so it’s not the correct choice.