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 A

Explanation

Choice A reason: Identifying the client's current stage of grief is crucial as it helps tailor the intervention to the client's specific needs. Understanding where the client is in the grieving process allows the nurse to provide appropriate emotional support and resources. It's the foundational step in managing complicated grief, as interventions may vary greatly depending on whether the client is in denial, anger, bargaining, depression, or acceptance.

Choice B reason: While physical activity can be beneficial for overall health and may help in managing symptoms of depression associated with grief, it is not the immediate priority. The nurse must first understand the client's emotional state before suggesting specific activities.

Choice C reason: Discussing the use of a spiritual grief counselor can be a valuable part of the healing process for some clients. However, this should come after assessing the client's beliefs and willingness to engage in spiritual counseling. It is not the first step in the care plan.

Choice D reason: Informing the client that feelings of anger are expected is part of educating the client about the grieving process. While it's important to normalize the range of emotions experienced during grief, it is more of a supportive intervention rather than a priority action.

A. A client who has conversion disorder B. A client who has mild anxiety disorder C. A client who has narcissistic personality disorder D. A client who has severe obsessive-compulsive disorder

Correct Answer is D

Explanation

Choice A reason: Conversion disorder involves neurological symptoms like paralysis or blindness that are not explainable by medical evaluation. While these symptoms may mimic sensory impairments, they are psychological in origin and not due to actual sensory deficits.

Choice B reason: Mild anxiety disorder typically does not involve sensory impairments. Anxiety may cause heightened awareness or sensitivity to stimuli but does not result in a loss of sensory function.

Choice C reason: Narcissistic personality disorder is characterized by patterns of grandiosity, need for admiration, and lack of empathy. It does not include sensory impairments as a symptom.

Choice D reason: Clients with severe obsessive-compulsive disorder (OCD) may experience sensory overload due to heightened focus on certain stimuli, leading to stress and anxiety. Assessing for risks related to sensory impairments can help in managing their symptoms and improving their quality of life.

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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 D

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