A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?

Asks the client what her plans are for follow-up care

Asks the client to sign a form releasing the hospital from legal responsibility

Shows the client her abnormal laboratory results

Asks security to detain the client until the provider is notified

Answer and Explanation

The Correct Answer is D

Rationale:

A. Asks the client what her plans are for follow-up care: This is an appropriate action that demonstrates concern for the client’s continuity of care and safety, even if she decides to leave against medical advice.

B. Asks the client to sign a form releasing the hospital from legal responsibility: This is standard practice when a client leaves against medical advice, as it documents that the client was informed of potential risks and chose to leave voluntarily.

C. Shows the client her abnormal laboratory results: Providing relevant medical information is appropriate to help the client make an informed decision about her care before leaving the facility.

D. Asks security to detain the client until the provider is notified: Clients have the legal right to leave a healthcare facility unless they are under specific legal or mental health holds. Detaining a competent adult against their will is unlawful and violates patient rights.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

Rationale:

Hallucinations: Auditory hallucinations, such as the client reporting listening to unseen others, are a hallmark symptom of psychosis. This indicates a break from reality and requires close psychiatric monitoring.
Lack of sleep: Sleep deprivation is common in manic episodes due to heightened energy and decreased need for rest. Chronic sleep loss in mania can exacerbate irritability, impulsivity, and cognitive impairment.
Pressured speech: Rapid, loud, and continuous speech is characteristic of mania. It reflects heightened energy, distractibility, and impaired judgment, often making communication difficult for caregivers.
Excessive spending habits: Impulsive financial decisions and risky behaviors, such as giving away large sums of money, are indicative of manic episodes. These behaviors can have serious social and financial consequences.
Disorganized thought process: Disorganized thinking can occur in both psychosis and mania. In psychosis, it may manifest as illogical or tangential thought patterns, while in mania, racing thoughts can disrupt coherent speech and planning.

A. "You have the right to refuse the procedure." B. "We can manage your care following the procedure without complications." C. "Your doctor thinks this surgery is necessary." D. "Let me review the procedure so you can understand what is going to happen."

Correct Answer is A

Explanation

A. "You have the right to refuse the procedure.": Clients have the legal and ethical right to refuse treatment at any time, including surgery. Acknowledging this respects the client’s autonomy and supports informed decision-making.

B. "We can manage your care following the procedure without complications.": This statement minimizes the client’s concerns and may be perceived as coercive. It does not address the client’s right to make an informed choice.

C. "Your doctor thinks this surgery is necessary.": Referencing the provider’s opinion without exploring the client’s concerns does not respect the client’s autonomy and may increase anxiety or pressure to comply.

D. "Let me review the procedure so you can understand what is going to happen.": While providing information is helpful, the client has already expressed refusal. This approach may be more appropriate if the client is undecided, but it does not acknowledge their right to decline.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

A nurse on a medical-surgical unit is caring for a client who states that she plans to leave the facility against medical advice. For which of the following actions by the nurse should the charge nurse intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client. For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A,B"}}

Explanation

A nurse is caring for a client who is scheduled for a surgical procedure and states, "I don't want to have this surgery anymore." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse on a mental health unit is admitting a client. Exhibits Select the 3 client findings the nurse should recognize as manifestations of water intoxication.

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A nurse is caring for a client who received a transfusion of 250 mL of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion?