A nurse is caring for a client who was voluntarily admitted to an acute mental health unit and asks, "You aren't going to make me take medication, are you?" Which of the following responses should the nurse make?
"If the provider prescribes medication, I will have to administer it.”.
"You agreed to take medication when you decided to be admitted.”.
"You have the right to refuse to take the medication.”.
"I can make a list of the medications that you don't want to take.”. . . .
The Correct Answer is C
Choice A rationale
"If the provider prescribes medication, I will have to administer it" is an inaccurate statement regarding a voluntarily admitted client's rights. Voluntarily admitted clients generally retain the right to refuse medication, even if it is prescribed by a provider. This response undermines the client's autonomy.
Choice B rationale
"You agreed to take medication when you decided to be admitted" is also generally inaccurate for voluntary admissions. While the client may agree to a treatment plan that includes medication, voluntary admission itself does not automatically equate to mandatory medication administration. The client still has the right to refuse.
Choice C rationale
"You have the right to refuse to take the medication" is the correct and most appropriate response. Voluntarily admitted clients retain their right to informed consent and the right to refuse treatment, including medication, unless there is a specific court order indicating otherwise or an imminent risk of harm to themselves or others. This response respects the client's autonomy.
Choice D rationale
"I can make a list of the medications that you don't want to take" is a helpful action in acknowledging the client's concern and preferences. However, it does not directly address the client's question about their right to refuse medication. While documenting preferences is important, the initial response should clearly state their right to refusal. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Asking a client with paranoid personality disorder why they are suspicious can be perceived as confrontational and challenging. Individuals with this disorder have a pervasive distrust of others, and directly questioning their suspicions is likely to increase their defensiveness and further impair the therapeutic relationship. A more indirect and gradual approach is necessary to build trust.
Choice B rationale
Using an overly friendly approach can be misinterpreted by a client with paranoid personality disorder. Their inherent distrust may lead them to suspect ulterior motives behind such excessive friendliness, making them more suspicious and resistant to forming a therapeutic alliance. A neutral and professional demeanor is more likely to be perceived as safe and trustworthy.
Choice C rationale
Being vague when answering a client's questions about instructions can exacerbate the mistrust inherent in paranoid personality disorder. Clear, consistent, and direct communication is essential to build trust and reduce suspicion. Vagueness can be interpreted as dishonesty or an attempt to deceive, further damaging the therapeutic relationship.
Choice D rationale
Demonstrating a neutral demeanor is the most appropriate strategy when beginning a therapeutic relationship with a client who has paranoid personality disorder. A neutral approach avoids appearing overly friendly or confrontational, allowing the client to feel safer and less threatened. This helps to establish a sense of predictability and trustworthiness, which is crucial for building rapport with individuals who are inherently suspicious of others' intentions.
Correct Answer is B
Explanation
Choice A rationale
Clang associations involve the meaningless rhyming of words, often seen in psychotic disorders. While this indicates a disturbance in thought processes, it does not pose an immediate threat to the client or others, making it a lower priority compared to potential harm.
Choice B rationale
Command hallucinations are auditory hallucinations that instruct the client to perform an action, which can be harmful to themselves or others. This requires immediate attention and assessment to ensure the client's safety and the safety of those around them.
Choice C rationale
Neologisms are newly coined words or phrases whose meaning is only understood by the client. This reflects disorganized thinking but does not indicate an immediate crisis or safety risk, making it a less urgent concern than command hallucinations.
Choice D rationale
Ideas of reference are false beliefs that irrelevant occurrences or details in the world directly relate to oneself. While these can cause distress, they do not typically involve an immediate risk of harm, making this a lower priority compared to command hallucinations.
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