A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make?
"I will make sure that we respect your right to refuse medications."
"You will need to rest so that you can recover from the episode that brought you here."
"Why do you think your provider will prescribe you medications that will make you sleep?"
"It's not your choice to be here, so you have to accept the treatment we plan for you."
The Correct Answer is A
A. "I will make sure that we respect your right to refuse medications." – This response respects the client's autonomy and reassures them that their rights will be upheld.
B. "You will need to rest so that you can recover from the episode that brought you here." – This statement dismisses the client's concerns rather than addressing them.
C. "Why do you think your provider will prescribe you medications that will make you sleep?" – While open-ended questions can encourage discussion, this does not directly reassure the client about their rights.
D. "It's not your choice to be here, so you have to accept the treatment we plan for you." – This statement is inappropriate and disregards the client's legal rights.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Report sudden, persistent headaches. – Correct. Persistent headaches may indicate a stroke, a severe complication of sickle cell anemia due to vaso-occlusion.
B. Restrict fluid intake during times of stress. – Incorrect. Hydration is crucial to prevent sickling of red blood cells. Fluids should be increased, not restricted.
C. Apply cold compresses to painful areas. – Incorrect. Cold can cause vasoconstriction and worsen sickling. Warm compresses are recommended instead.
D. Avoid meningococcal immunizations. – Incorrect. Children with sickle cell anemia are at increased risk for infections and should receive all recommended vaccinations, including the meningococcal vaccine.
Correct Answer is A
Explanation
A. This is the correct answer. Older adults are at risk for fluid overload, so infusing blood over 4-5 hours (instead of the usual 2-4 hours) is safer.
B. Blood products must be infused with 0.9% sodium chloride (normal saline) only. Dextrose-containing solutions cause hemolysis.
C. A 20-gauge catheter is acceptable, but a larger bore (18-gauge) is preferred for faster infusion.
D. Vital signs should be monitored before the transfusion, 15 minutes after starting, then every 30-60 minutes, and at completion.
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