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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.

A. Lack of empathy B. Preoccupation with details C. Exploitative behavior D. Excessive clinging

Correct Answer is B

Explanation

Choice A reason: Intensive Outpatient Programs (IOPs) offer structured treatment for mental health and substance misuse concerns, providing therapy for a few hours a day, several days a week. While beneficial, they may not offer the comprehensive, round-the-clock support needed by someone with a chronic mental illness.

Choice B reason: Assertive Community Treatment (ACT) is a form of community-based mental health care designed to help individuals with serious mental illnesses manage their symptoms and live independently in the community. ACT involves a multidisciplinary team approach and provides round-the-clock services, making it an ideal resource for chronic mental illness management.

Choice C reason: Patient-Centered Medical Homes (PCMHs) focus on providing comprehensive, coordinated care that is patient-centered and culturally appropriate. Although PCMHs offer a broad range of services, they may not be as intensive as ACT for managing chronic mental illness.

Choice D reason: Partial Hospitalization Programs (PHPs) are intensive outpatient treatment programs that allow patients to live at home while receiving daily treatment at a facility. PHPs are more intensive than IOPs but less so than inpatient care, and they may not provide the continuous support that ACT offers for chronic mental illness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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