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 health care team.
Which of the following actions should the nurse take?
Tell the client he cannot refuse the treatment because he was involuntarily committed.
Document the client's refusal of the treatment in the medical record.
Inform the client that ECT does not require client consent.
Ask the client's family to encourage the client to receive ECT.
The Correct Answer is B
Choice A rationale:
(Statement then rationale) Choice A is not the correct option. Involuntary commitment does not strip a person of their right to refuse treatment. It is essential to respect the client's autonomy and their right to refuse treatment, even in the case of involuntary commitment. This approach promotes ethical and legal principles related to informed consent and patient rights.
Choice C rationale:
(Statement then rationale) Choice C is also not the correct option. Electroconvulsive therapy (ECT) does indeed require client consent. Informed consent is a fundamental aspect of medical treatment, and healthcare providers must obtain the patient's permission before administering any procedure or treatment, including ECT.
Choice D rationale:
(Statement then rationale) Choice D is not the correct answer either. Involving the client's family without their consent is not appropriate. The decision to accept or refuse treatment should remain with the client, and their autonomy should be respected. Coercing the client through their family would be ethically and legally problematic. Now, let's move on to the next question.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Having a flat affect is not a specific indicator of delirium. A flat affect may be seen in various mental health conditions and is not unique to delirium. Delirium is characterized by acute changes in cognitive function and awareness, and a flat affect alone does not fulfill the criteria for diagnosing delirium.
Choice B rationale:
The client's speech being slow and repetitious is not a specific finding that leads to a suspicion of delirium. While changes in speech can be observed in delirium, this finding alone is not sufficient to diagnose delirium. Delirium is more about changes in consciousness, attention, and cognition.
Choice D rationale:
The client's inability to recognize objects is not a specific indicator of delirium. Delirium is characterized by a fluctuating level of consciousness and changes in cognitive function. Inability to recognize objects might be a symptom of other conditions, but it is not a hallmark sign of delirium.
Choice C rationale:
The client's manifestations developing suddenly is a key indicator of delirium. Delirium is characterized by an acute and rapid onset of cognitive and perceptual disturbances. It is often caused by an underlying medical condition or medication side effects and is typically reversible. The sudden development of symptoms is a significant clue in suspecting delirium and should prompt further evaluation and intervention. .
Correct Answer is D
Explanation
The correct answer is D. Hyperthermia.
Choice A reason: Hyperglycemia, which is an elevated blood glucose level, is not typically a direct manifestation of alcohol withdrawal. Alcohol withdrawal can sometimes lead to poor oral intake or vomiting, which might indirectly affect blood sugar levels, but hyperglycemia itself is not a primary concern in the context of alcohol withdrawal.
Choice B reason: Decreased blood pressure During alcohol withdrawal, the sympathetic nervous system is often overactive, leading to symptoms such as increased blood pressure, rather than decreased. Therefore, decreased blood pressure is not a common manifestation of alcohol withdrawal. Normal blood pressure ranges for adults are systolic BP of 100-120mmHg and diastolic BP of 70-80mmHg.
Choice C reason: Decreased heart rate Similar to blood pressure, the heart rate typically increases during alcohol withdrawal due to sympathetic nervous system overactivity. A normal resting heart rate for adults ranges from 60 to 100 beats per minute (bpm). Decreased heart rate is not expected during alcohol withdrawal.
Choice D reason: Hyperthermia, or elevated body temperature, is a common symptom of alcohol withdrawal. This occurs as part of the body’s response to the sudden absence of alcohol, and can be a part of the withdrawal syndrome, which includes a range of symptoms from mild anxiety to severe complications like seizures. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).
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