A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

Explain to the client the consequences of refusal.

Identify the reason for the client's refusal.

Document the client's refusal in the medical record.

Inform the provider of the client's refusal.

Answer and Explanation

The Correct Answer is B

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

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Correct Answer is B

Explanation

A. Failure to engraft typically presents with symptoms such as persistent neutropenia, thrombocytopenia, and anemia, rather than skin peeling.

B. Veno-occlusive disease, also known as sinusoidal obstruction syndrome, can lead to liver dysfunction and subsequent skin manifestations such as peeling, especially on the palms and soles.

C. Graft-versus-host disease (GVHD) typically presents with symptoms such as skin rash, diarrhea, and liver dysfunction, but peeling skin is not a hallmark manifestation.

D. Pancytopenia refers to a deficiency of all types of blood cells (red blood cells, white blood cells, and platelets) and is not typically associated with skin peeling as a primary symptom.

A. "Do you understand HIPAA regulations?" B. "This discussion is only appropriate in a private area." C. "Please stop this discussion." D. "Did you know you can be liable if you breach confidentiality?"

Correct Answer is C

Explanation

A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.

B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.

C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.

D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.

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A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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