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 ["A","D","E"]
Explanation
Choice A rationale
Access to firearms in the home significantly increases the risk of suicide because firearms are highly lethal and provide a quick and often impulsive means of ending one's life. The availability of a firearm reduces the time between suicidal ideation and action, making intervention more difficult.
Choice B rationale
A sibling history of suicide can increase an individual's risk due to potential genetic predispositions to mental health disorders or learned behaviors and coping mechanisms within the family. However, it is not as direct or immediate a risk factor as other factors.
Choice C rationale
Being currently unmarried can be a contributing factor to social isolation and lack of support, which are risk factors for suicide. However, marital status alone is not a strong predictor of suicide risk, as many unmarried individuals have strong social networks, and married individuals can still experience isolation.
Choice D rationale
Expressing feelings of hopelessness is a critical warning sign for suicide. Hopelessness is a state of despair where an individual believes their situation will never improve, leading to a sense of futility and a higher likelihood of considering suicide as an escape.
Choice E rationale
A recent significant loss, such as the death of a loved one, a job loss, or the end of a significant relationship, can trigger intense emotional distress and increase vulnerability to suicidal ideation, especially if the individual lacks adequate coping mechanisms or social support. .
Correct Answer is A
Explanation
Choice A rationale
Cardiac arrhythmia is a significant concern prior to electroconvulsive therapy (ECT) because ECT involves inducing a brief seizure. The physiological stress of a seizure can exacerbate pre-existing cardiac conditions, potentially leading to serious complications such as further arrhythmias or cardiac arrest. Therefore, any history of cardiac arrhythmia should be reported to the provider for careful evaluation and management before proceeding with ECT.
Choice B rationale
Crohn's disease is a chronic inflammatory bowel disease and is not a direct contraindication for ECT. While the client's overall health is considered, Crohn's disease does not pose an immediate risk of serious complications during or after the ECT procedure itself. The focus for ECT contraindications is primarily on neurological and cardiovascular conditions.
Choice C rationale
Asthma is a chronic respiratory condition characterized by airway inflammation and bronchoconstriction. While it requires careful management, asthma is not typically a direct contraindication for ECT. Precautions would be taken to ensure adequate oxygenation during the procedure, but it does not inherently increase the risk of severe complications related to the induced seizure.
Choice D rationale
Renal colic, which is pain associated with kidney stones, is an acute condition but not a direct contraindication for ECT. While the client's comfort and pain management would be important considerations, renal colic does not increase the risk of serious complications related to the seizure induced by ECT. The primary concerns for ECT are conditions that could be negatively impacted by the seizure activity.
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