A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

Keep the client hospitalized until there is no longer a threat.

Ensure the client's ex-partner is notified of the threat.

Ask a friend or family member to monitor the client.

Transfer the client to a mental health facility.

Answer and Explanation

The Correct Answer is B

A reason: Keep the client hospitalized until there is no longer a threat. The nurse does not have the authority to independently keep the client hospitalized based on the threat. This decision involves a multidisciplinary approach and, if necessary, legal intervention.

B reason: Ensure the client's ex-partner is notified of the threat. The nurse has a legal and ethical duty to warn individuals who are at risk of harm. Ensuring the ex-partner is notified of the threat is an essential step to protect them from potential danger.

C reason: Ask a friend or family member to monitor the client. While involving friends or family in the client's care is important, it is not the primary legal duty in this situation. Professional intervention and appropriate authorities should be notified.

D reason: Transfer the client to a mental health facility. Transferring the client to a mental health facility may be necessary for their safety and well-being, but the immediate legal duty is to ensure the threatened individual is informed and protected.

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Correct Answer is C

Explanation

A reason: Voice alteration. Voice alteration is not a common adverse effect of ECT. The procedure typically does not impact vocal cords or speech directly.

B reason: Neck pain. While discomfort and muscle soreness can occur, neck pain is not a primary or common adverse effect specifically associated with ECT.

C reason: Memory deficit. Memory deficits, particularly short-term memory loss, are a well-documented adverse effect of ECT. Clients may experience difficulty recalling recent events before and after treatment.

D reason: Headache. Headache can occur after ECT but is less concerning compared to cognitive side effects like memory deficits. Monitoring for memory changes is crucial.

A. Cognitive reframing. B. Thought stopping. C. Validation therapy. D. Operant conditioning.

Correct Answer is C

Explanation

A reason: Cognitive reframing. Cognitive reframing involves changing the way a person thinks about a situation to reduce stress or anxiety. While useful in some cases, it is not the most appropriate technique for addressing delusions in clients with dementia.

B reason: Thought stopping. Thought stopping is a technique used to interrupt and control intrusive thoughts, often used in cognitive-behavioral therapy. It is not suitable for managing the delusions of a client with dementia.

C reason: Validation therapy. Validation therapy involves accepting the client's perception of reality and responding in a way that acknowledges their feelings and experiences. For a client with dementia who believes a doll is their infant child, validation therapy helps provide comfort and reduces distress by not challenging their beliefs.

D reason: Operant conditioning. Operant conditioning involves using reinforcement to encourage desired behaviors and discourage undesired ones. It is not appropriate for addressing the delusions of a client with dementia, as it does not validate their experiences.

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A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has undergone electroconvulsive therapy (ECT). The nurse should monitor the client for which of the following adverse effects of ECT?

Correct Answer is C

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Correct Answer is C

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