A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral anti-anxiety medication. Which of the following actions should the nurse take?
Administer the medication to the client via IM injection.
Offer the client the medication at the next scheduled dose time.
Inform the client that they do not have the right to refuse the medication.
Implement consequences until the client takes the medication.
The Correct Answer is B
Choice A reason: Administering the medication via IM injection against the client's will can be considered a violation of the client's rights, especially in the context of mental health care where consent and autonomy are highly valued. Involuntary treatment, including medication administration, should only be considered in situations where the client poses an immediate risk to themselves or others, which is not indicated in the scenario provided.
Choice B reason: Offering the medication at the next scheduled dose time respects the client's current decision to refuse the medication while also maintaining the prescribed treatment plan. It allows time for the client to reconsider their decision and provides an opportunity for the nurse to engage in further discussion about the benefits and importance of the medication, potentially addressing any concerns or fears the client may have.
Choice C reason: Informing the client that they do not have the right to refuse medication is incorrect and unethical. Patients have the right to informed consent, which includes the right to refuse treatment. This is particularly important in mental health care, where respecting the client's autonomy and rights is essential for building trust and promoting recovery.
Choice D reason: Implementing consequences for refusing medication is coercive and can damage the therapeutic relationship between the nurse and the client. It may also lead to increased resistance and distrust from the client, which can negatively impact their overall care and treatment outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with certain foods containing tyramine, such as cheese, leading to hypertensive crisis. The client's report of dizziness after eating a grilled cheese sandwich could indicate a spike in blood pressure. Therefore, assessing blood pressure is the priority to check for this potential adverse reaction.
Choice B reason: While respiration is important, it is not typically the first vital sign affected by the dietary interaction with phenelzine. However, if blood pressure is elevated, it could lead to respiratory changes, so it should be monitored if blood pressure is abnormal.
Choice C reason: Pulse may be affected by changes in blood pressure, but it is not the most direct indicator of a hypertensive crisis. After assessing blood pressure, the nurse should also check the pulse for any irregularities.
Choice D reason: Temperature is not directly related to the symptoms of a hypertensive crisis caused by MAOI interactions with tyramine-rich foods. It is unlikely that the client's dizziness is related to a change in body temperature.
Correct Answer is B
Explanation
The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.
Choice A reason:
Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.
Choice B reason:
Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.
Choice C reason:
Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.
Choice D reason:
Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.