A nurse is assessing a client during a follow-up at a health clinic. The client reports that they struggle to take antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?

Tell the client they will be admitted to an inpatient care facility if they do not take the medication.

Discuss the provider's goals for the client's care.

Ask the client if the medication is causing adverse effects.

Request the provider prescribe a second antipsychotic medication to the client.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Telling the client that they will be admitted to an inpatient care facility if they do not take their medication can be perceived as a threat and may damage the therapeutic relationship. It is not an effective strategy for improving medication adherence, as it does not address the underlying reasons for the client's struggle with taking the medication.

Choice B reason:
Discussing the provider's goals for the client's care is important, but it does not directly address the issue of medication adherence. While understanding the treatment plan can be beneficial, it is more crucial to engage the client in a conversation about their experiences and concerns with the medication.

Choice C reason:
Asking the client if the medication is causing adverse effects is a direct approach to understanding potential barriers to medication adherence. Adverse effects can be a significant reason why clients may be reluctant to take their medication regularly. Addressing these concerns can lead to adjustments in the medication regimen that may improve adherence.

Choice D reason:
Requesting the provider to prescribe a second antipsychotic medication is not an appropriate first step without first understanding the reasons for non-adherence. Adding another medication could complicate the regimen and potentially lead to more adverse effects or interactions.

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Correct Answer is ["A","C","D","F","G"]

Explanation

Choice A: Gastrointestinal assessment
The client reports weight loss and minimal appetite over the past 3 months. This is significant because chronic alcohol use can lead to malnutrition, gastrointestinal issues, and liver damage. Weight loss and poor appetite may indicate underlying conditions such as gastritis, pancreatitis, or liver disease, which require further evaluation and intervention.
Choice B: Smoking history
The client quit smoking over 20 years ago and has no current respiratory issues. While smoking history is important for a comprehensive health assessment, it does not require immediate follow-up in this context as it is not directly related to the current acute issues of alcohol intoxication and potential withdrawal.
Choice C: Blood alcohol level
The client’s blood alcohol level (BAC) is 310 mg/dL, which is significantly elevated (normal range: 0 to 50 mg/dL). This level of intoxication can lead to severe complications such as respiratory depression, aspiration, and even death. Immediate medical intervention is necessary to manage the acute effects of alcohol intoxication and to monitor for withdrawal symptoms.
Choice D: Client’s recent loss
The recent death of the client’s parents is a significant emotional stressor that has contributed to the relapse of alcohol use disorder. Addressing this loss is crucial for the client’s mental health and recovery process. The nurse should ensure that the client receives appropriate psychological support and counseling to cope with this loss1.
Choice E: Genitourinary assessment
The client reports no known genitourinary problems. Therefore, this area does not require immediate follow-up in the context of the current admission for alcohol use disorder.
Choice F: Client’s recent consumption of alcohol
The client had their last drink 2 hours ago. This information is critical for monitoring potential alcohol withdrawal symptoms, which can begin within a few hours after the last drink and can be life-threatening if not properly managed. Close monitoring and timely intervention are essential
Choice G: Neurological assessment
The client is intoxicated, has slurred speech, and is unable to coherently respond to questions. These neurological symptoms indicate significant alcohol intoxication and the potential for withdrawal symptoms. Continuous neurological assessment is necessary to monitor for any changes in mental status and to prevent complications.
Choice H: Cardiac assessment
The client has a normal sinus rhythm and palpable pulses with no history of heart disease. While cardiac assessment is always important, there are no immediate concerns in this context that require follow-up.
Choice I: Respiratory assessment
The client’s respiratory rate is 10/min, which is on the lower end of normal (normal range: 12-20/min). However, the client has clear lungs and no shortness of breath. While respiratory status should be monitored, it is not an immediate concern requiring follow-up in this context.

A. The client demonstrates that they are oriented to person, place, and time. B. The client refuses to take their medication unless they are released. C. The client states that they will harm themselves unless the restraints are removed. D. The client is able to follow commands.

Correct Answer is A

Explanation

Choice A reason:
The ability to demonstrate orientation to person, place, and time suggests that the client has regained a level of cognitive functioning that may indicate they are no longer a danger to themselves or others. This is a key factor in determining when it is safe to remove physical restraints. It shows that the client can understand and interact with their environment in a meaningful way.

Choice B reason:
While a client's refusal to take medication is a concern, using it as a condition to release them from restraints could reinforce negative behavior. The decision to remove restraints should be based on the client's behavior and mental status, not on conditions set by the client.

Choice C reason:
If a client threatens self-harm if restraints are not removed, this could indicate that they are still experiencing significant distress and may not be ready to have the restraints removed safely. The threat of self-harm needs to be addressed with appropriate interventions and assessments.

Choice D reason:
The ability to follow commands is important, but it is not the sole indicator for the removal of restraints. The overall assessment of the client's mental status, including orientation and risk of harm to self or others, must be considered.

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A nurse is assessing a client during a follow-up at a health clinic. The client reports that they struggle to take antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","C","D","F","G"]

Explanation

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

Correct Answer is A

Explanation

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