A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
Encouraging client feedback about satisfaction with the facility experience
Explaining unit rules and policies regarding unacceptable behaviors
Supporting the client's wish to refuse prescribed medications
Making sure the client understands expectations for client participation
The Correct Answer is C
Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.
B) Explaining unit rules and policies regarding unacceptable behaviors:
Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.
C) Supporting the client's wish to refuse prescribed medications.
Explanation:
Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.
D) Making sure the client understands expectations for client participation:
Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.
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Correct Answer is C
Explanation
A. Discuss the problem in a community meeting with the other clients on the unit present.
While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.
B. Escort the client to her room each time the nurse observes the client socializing with other clients.
This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.
C. Talk to the client and identify the specific limits that are required of the client's behavior.
This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.
D. Tell the other clients to ignore the client's lies.
While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.
Correct Answer is A
Explanation
A. Determining if the client has psychotic thinking.
Explanation: The highest priority assessment in this situation is to determine if the client has psychotic thinking. Psychotic thinking can indicate a severe mental health condition that requires immediate attention and intervention. If the client is experiencing psychotic symptoms, they might be at risk of harming themselves or others. Identifying and addressing psychotic thinking is crucial to ensure the safety and well-being of the client and those around them.
B. Asking the client to identify the cause of the crisis.
While understanding the cause of the crisis is important for providing appropriate care, it is not the highest priority. Psychotic thinking or risk of harm takes precedence over understanding the cause.
C. Identifying the client's coping skills.
Coping skills are important for managing the crisis and promoting the client's well-being, but assessing for psychotic thinking and immediate safety concerns comes before evaluating coping skills.
D. Identifying the client's support systems.
Support systems are valuable for the client's overall recovery, but they are not as time-sensitive as assessing for psychotic thinking or imminent safety risks. Identifying support systems can come after addressing the immediate concerns.
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