A nurse is assisting with the involuntary admission of a client who has an anxiety disorder and is unable to meet their basic physical needs. Which of the following statements should the nurse make to the client?
"You have the right to refuse medications prescribed during your stay."
"Your admission status allows you to leave the facility at any time."
"Your health care team will review your admission status in 90 days."
"You will automatically have a legal guardian appointed during this admission."
The correct answer is: a) "You have the right to refuse medications prescribed during your stay."
The Correct Answer is A
Choice A reason: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.
Choice B reason: This statement is incorrect because involuntary admission means that the client cannot leave the facility at any time. Involuntary admission is typically initiated because the client is unable to meet their own physical needs or poses a danger to themselves or others. Therefore, their ability to leave the facility is restricted until their condition improves or their admission status is reviewed and changed.
Choice C reason: This statement is misleading because the review of admission status for involuntary patients usually occurs much sooner than 90 days. Legal requirements and procedures for reviewing involuntary admission status vary by jurisdiction, but typically, initial reviews occur within a few days to weeks to ensure that the client's rights are protected and that continued hospitalization is necessary.
Choice D reason: This statement is incorrect. Involuntary admission does not automatically result in the appointment of a legal guardian. The process of appointing a legal guardian is separate and involves a legal proceeding where a court determines the need for guardianship. The involuntary admission process is primarily focused on the immediate care and safety of the client.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Keeping the client's bedroom area dark at night is not advisable for individuals with Alzheimer's disease who wander. Darkness can increase confusion and the risk of falls. It is better to have a night light or dim lighting to help the client navigate safely if they get up during the night. Proper lighting can reduce disorientation and provide a safer environment for those who wander.
Choice B reason: Having the client exercise 30 minutes before bedtime is not recommended. Exercise close to bedtime can be stimulating and might make it more difficult for the client to fall asleep. It is generally advised to avoid vigorous physical activity at least a few hours before bedtime to promote better sleep. Gentle activities earlier in the day can help improve sleep quality without causing overstimulation.
Choice C reason: Placing the client's mattress on the bedroom floor is a practical safety measure for clients with Alzheimer's disease who wander at night. This approach minimizes the risk of injury from falls, as the client will be closer to the ground. By reducing the height of the bed, families can create a safer sleeping environment and help prevent potential injuries due to wandering and confusion.
Choice D reason: Encouraging the client to nap often during the day can disrupt nighttime sleep patterns. Excessive daytime napping can lead to difficulties falling asleep at night and contribute to nighttime wandering. It is essential to maintain a balanced routine with limited napping during the day to promote better sleep at night. Structured activities and proper sleep hygiene can help improve nighttime rest.
Correct Answer is C
Explanation
Choice A reason: Hypoactive bowel sounds can indicate a variety of gastrointestinal issues, but they are not typically associated with haloperidol use. While it is important to monitor bowel sounds, it is not the priority in this context.
Choice B reason: Dry mouth is a common side effect of many medications, including haloperidol. While it can be uncomfortable for the client, it is not usually a serious concern and can be managed with hydration and other supportive measures.
Choice C reason: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.
Choice D reason: Photosensitivity is not a common side effect of haloperidol. While it is important to monitor for any new or unusual symptoms, photosensitivity is not typically associated with this medication.
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