A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?
The client can undergo electroconvulsive therapy without giving informed consent.
The nurse can share information with the client's family without his permission.
The client has the right to refuse medication.
The nurse may use restraints as needed (PRN).
The Correct Answer is C
Choice A reason: Electroconvulsive therapy (ECT) requires informed consent, as it is a significant medical procedure involving anesthesia and induced seizures. Informed consent is a process where a patient is fully informed about the procedures and risks involved in a treatment and voluntarily agrees to it.
Choice B reason: Nurses cannot share information with a client's family without the client's permission due to confidentiality laws, except in specific circumstances defined by law. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA), which requires patient consent for disclosure.
Choice C reason: Patients have the right to refuse medication. This right is part of the patient's autonomy and informed consent process. A mentally competent adult can refuse treatment, even if it may result in serious illness or death.
Choice D reason: The use of restraints in mental health facilities is highly regulated. Restraints may only be used when necessary to prevent immediate harm to the patient or others and must be discontinued as soon as the risk of harm has subsided.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.
Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
Correct Answer is D
Explanation
Choice A reason: While it may be beneficial for the client's mood, taking the client out of the facility does not directly address the sudden change in behavior.
Choice B reason: Rewarding the client for a change in behavior does not address the potential risks associated with a sudden change in mental status.
Choice C reason: Asking the client why their behavior has changed could be part of an assessment, but it is not an immediate safety intervention.
Choice D reason: Monitoring the client's whereabouts at all times is important as a sudden lift in depressive symptoms can sometimes precede a suicide attempt, and close observation is necessary.
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