A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?

Ask the client's family to encourage the client to receive ECT.

Tell the client they cannot refuse the treatment because they were involuntarily committed.

Document the client's refusal of the treatment in the medical record.

Inform the client that ECT does not require client consent.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Asking the client's family to encourage the client to receive ECT may be a supportive measure, but it should not be the first action taken. The client's autonomy and right to refuse treatment must be respected, even if they are involuntarily committed. Family members can be involved in the discussion, but the client's decision should be paramount.

Choice B reason:
Telling the client they cannot refuse treatment because they were involuntarily committed is incorrect. Involuntary commitment does not automatically override a client's right to refuse treatment. Clients have the right to be informed about their treatment and to refuse it unless specific legal criteria are met.

Choice C reason:
Documenting the client's refusal of the treatment in the medical record is the correct action. It is essential to record the client's decision and the discussion surrounding it. This documentation ensures that the client's rights are respected and provides a legal record of the interaction.

Choice D reason:
Informing the client that ECT does not require client consent is incorrect and unethical. Consent is a fundamental patient right, and all clients, including those involuntarily committed, have the right to be informed about their treatment options and to give or withhold consent unless they are legally deemed incompetent to make such decisions.

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Correct Answer is ["A","C","D","F","G"]

Explanation

Choice A: Gastrointestinal assessment
The client reports weight loss and minimal appetite over the past 3 months. This is significant because chronic alcohol use can lead to malnutrition, gastrointestinal issues, and liver damage. Weight loss and poor appetite may indicate underlying conditions such as gastritis, pancreatitis, or liver disease, which require further evaluation and intervention.
Choice B: Smoking history
The client quit smoking over 20 years ago and has no current respiratory issues. While smoking history is important for a comprehensive health assessment, it does not require immediate follow-up in this context as it is not directly related to the current acute issues of alcohol intoxication and potential withdrawal.
Choice C: Blood alcohol level
The client’s blood alcohol level (BAC) is 310 mg/dL, which is significantly elevated (normal range: 0 to 50 mg/dL). This level of intoxication can lead to severe complications such as respiratory depression, aspiration, and even death. Immediate medical intervention is necessary to manage the acute effects of alcohol intoxication and to monitor for withdrawal symptoms.
Choice D: Client’s recent loss
The recent death of the client’s parents is a significant emotional stressor that has contributed to the relapse of alcohol use disorder. Addressing this loss is crucial for the client’s mental health and recovery process. The nurse should ensure that the client receives appropriate psychological support and counseling to cope with this loss1.
Choice E: Genitourinary assessment
The client reports no known genitourinary problems. Therefore, this area does not require immediate follow-up in the context of the current admission for alcohol use disorder.
Choice F: Client’s recent consumption of alcohol
The client had their last drink 2 hours ago. This information is critical for monitoring potential alcohol withdrawal symptoms, which can begin within a few hours after the last drink and can be life-threatening if not properly managed. Close monitoring and timely intervention are essential
Choice G: Neurological assessment
The client is intoxicated, has slurred speech, and is unable to coherently respond to questions. These neurological symptoms indicate significant alcohol intoxication and the potential for withdrawal symptoms. Continuous neurological assessment is necessary to monitor for any changes in mental status and to prevent complications.
Choice H: Cardiac assessment
The client has a normal sinus rhythm and palpable pulses with no history of heart disease. While cardiac assessment is always important, there are no immediate concerns in this context that require follow-up.
Choice I: Respiratory assessment
The client’s respiratory rate is 10/min, which is on the lower end of normal (normal range: 12-20/min). However, the client has clear lungs and no shortness of breath. While respiratory status should be monitored, it is not an immediate concern requiring follow-up in this context.

A. Nausea and vomiting B. Confusion C. Tachycardia D. Hypothermia E. Amnesia F. Respiratory depression

Correct Answer is ["A","B","E","F"]

Explanation

Choice A:
GHB (gamma-hydroxybutyric acid) is known to cause nausea and vomiting, especially at higher doses. These symptoms are common side effects of GHB ingestion and can be distressing for the patient.
Choice B:
Confusion is a significant complication associated with GHB use. GHB acts as a central nervous system depressant, leading to altered mental status and confusion. This can impair the patient’s ability to communicate effectively and understand their surroundings.
Choice C:
Tachycardia, or an abnormally fast heart rate, is not typically associated with GHB use. GHB tends to cause bradycardia (slowed heart rate) rather than tachycardia. Therefore, this option is not a correct answer.
Choice D:
Hypothermia, or abnormally low body temperature, is not a common complication of GHB use. GHB does not typically affect body temperature regulation in a way that would lead to hypothermia. Thus, this option is not a correct answer.
Choice E:
Amnesia is a well-documented effect of GHB, often referred to as the “date rape drug” due to its ability to cause memory loss1. This can result in the patient having no recollection of events that occurred while under the influence of the drug.
Choice F:
Respiratory depression is a severe and potentially life-threatening complication of GHB use. GHB can depress the central nervous system to the point where breathing becomes slow and shallow, which can lead to respiratory failure5. This is a critical concern in managing patients who have ingested GHB.

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A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the healthcare team. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","C","D","F","G"]

Explanation

The nurse is continuing to care for the patient in the emergency department. Exhibits Which findings should the nurse identify as potential complications of the client’s diagnostic results? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

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