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?
"It's not your choice to be here, so you have to accept the treatment we plan for you.”
"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?”
"I will make sure that we respect your right to refuse medications.”
The Correct Answer is D
Choice A rationale:
Telling the client, "It's not your choice to be here, so you have to accept the treatment we plan for you," disregards the client's autonomy and right to make decisions about their own healthcare. In mental health settings, respecting a patient's autonomy and involving them in the decision-making process is crucial for ethical care. This statement does not address the client's fear or provide any reassurance.
Choice B rationale:
Choice C rationale:
Asking, "Why do you think your provider will prescribe you medications that will make you sleep?" attempts to explore the client's fear, but it may come across as dismissive or invalidating. It could make the client feel unheard or misunderstood, which is not ideal in this situation.
Choice D rationale:
Stating, "I will make sure that we respect your right to refuse medications," is the most appropriate response. It acknowledges the client's fear and reassures them that their autonomy will be respected. It opens the door for a discussion about the client's concerns, allowing them to express their fears and preferences. Respecting the client's right to refuse medications is fundamental to ethical nursing practice and patient-centered care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Instructing the client to maintain a full bladder is not relevant to an amniocentesis procedure. A full bladder may be necessary for certain other procedures, such as a pelvic ultrasound, but not for amniocentesis.
Choice B rationale:
Administering a tocolytic 30 minutes before the procedure is not a standard practice for amniocentesis. Tocolytics are medications used to suppress uterine contractions and are not routinely administered before this procedure.
Choice C rationale:
Monitoring the fetal heart rate throughout the procedure is essential during an amniocentesis. This helps assess the well-being of the fetus and ensures that the procedure is not causing fetal distress. Any changes in fetal heart rate can indicate potential complications and may require immediate intervention.
Choice D rationale:
Placing the client in Trendelenburg position during the procedure is not recommended for amniocentesis. Trendelenburg position, where the body is supine with the legs elevated higher than the head, is not routinely used during this procedure and may cause discomfort to the client without providing significant clinical benefits.
Correct Answer is ["A","C","E"]
Explanation
Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.
The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.
Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.
The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.
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