A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

Inform the client that a family member will be called to see if they can help.

Prepare discharge paperwork since the client is refusing assistance.

Set clear boundaries for behavior and allow the refusal of medication.

Inform the client that without the medications, their mental status will not improve.

Answer and Explanation

The Correct Answer is C

When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.

Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.

The other options are not appropriate for the following reasons:

A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.

B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.

D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.

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Correct Answer is B

Explanation

Explanation: The priority question the nurse should ask the client during the initial assessment is whether they feel safe in their home (Option B). This question is essential because it addresses the client's safety and well-being, particularly regarding the possibility of domestic violence or intimate partner violence.

Assessing for safety is a critical component of the initial assessment, especially for female clients, as they may be at higher risk for experiencing domestic violence or abuse. By asking about the client's safety in their home, the nurse can identify potential issues related to violence or unsafe living conditions and take appropriate actions to ensure the client's safety.

Options A, C, and D are also important assessment questions, but they are not the priority in this scenario:

A. "Do you have enough money to pay for your care today?" - This is an important question regarding the client's financial situation and ability to access healthcare. However, safety and well-being take precedence over financial concerns in the initial assessment.

C. "Do you take illegal street drugs?" - This question is crucial for assessing the client's substance use and potential risk factors related to drug use. However, the safety question (Option B) is more immediate and directly addresses the client's well-being.

D. "Do you obtain regular medical care?" - This question is vital for assessing the client's healthcare needs and access to healthcare services. However, the safety question (Option B) should be addressed first to ensure the client's immediate safety and well-being.

A. A driver whose spouse and children all died as a result of his driving drunk B. An adult who insisted for many years that the adult hated the adult's deceased parent C. The parent of a child who died after having left the child in a car on a hot day D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day E. The spouse of a person who died 7 years ago and visits the grave several times a day

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

Explanation

Complicated grieving, also known as complicated grief or prolonged grief disorder, refers to a type of grief that is prolonged, intense and does not follow the typical trajectory of mourning. It can manifest differently in different individuals, but some common signs of complicated grieving include:

B. An adult who insisted for many years that the adult hated the adult's deceased parent: This could indicate unresolved emotional conflicts with the deceased parent, which may be contributing to complicated grief.

C. The parent of a child who died after having left the child in a car on a hot day: This situation involves feelings of guilt and responsibility, which can complicate the grieving process.

D. The grandchild of a soldier killed in war who visits the grave once a year on Memorial Day: This response is likely a normal grief response, as the person visits the grave once a year during Memorial Day, which is a common time for remembering and honoring deceased loved ones.

The following options are not necessarily indicative of complicated grieving:

A. A driver whose spouse and children all died as a result of his driving drunk: While this is undoubtedly a traumatic event, the description provided does not necessarily indicate complicated grieving specifically.

E. The spouse of a person who died 7 years ago and visits the grave several times a day: Visiting the grave several times a day might indicate a deep sense of loss, but it is not specific to complicated grieving and can vary depending on cultural practices and individual coping mechanisms.

It's essential to recognize that grief is a complex and individual process, and professional assessment and support are often required to identify and address complicated grieving in a person.

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A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse working in an outpatient clinic is performing an intake assessment for a female client. Which priority question will the nurse ask the client as part of the initial assessment?

Correct Answer is B

Explanation

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

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

Explanation

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse. "What do you think about that?" Which is the best response by the nurse?

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The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?

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A nurse is working with a client who has frequent angry outbursts which is disrupting life at home. Which statement by the nurse is most helpful when working with this client?