An elderly patient with advanced Alzheimer’s disease is admitted to the unit. The nurse is informed that the patient has a court-appointed legal guardian. The guardian arrives and asks for information about the patient’s medications and plan of care. What is the nurse’s best response?

I must check with the physician first to approve releasing this information.

I cannot share that information without the patient’s consent.

Only immediate family members are allowed to receive medical updates.

I’d be happy to provide an update on the medications and care plan.

Answer and Explanation

The Correct Answer is D

Choice A reason: Checking with the physician before releasing information to a legal guardian is unnecessary, as guardians have legal authority to access patient information. This response delays care coordination and disregards the guardian’s role, potentially hindering decision-making, making it incorrect.

Choice B reason: Requiring patient consent is inappropriate for a patient with advanced Alzheimer’s, who lacks decision-making capacity. The court-appointed guardian has legal authority to receive medical information, as they act in the patient’s best interest, making this response incorrect.

Choice C reason: Restricting information to immediate family ignores the legal guardian’s authority. Guardians, regardless of family status, are legally entitled to medical updates to make informed care decisions, as they represent the patient’s interests, making this response incorrect.

Choice D reason: Providing the guardian with medication and care plan updates is appropriate, as they have legal authority to make healthcare decisions for the patient. This ensures informed decision-making and complies with legal and ethical standards, making this the correct choice.

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Correct Answer is A

Explanation

Choice A reason: Withdrawn behavior and avoiding eye contact suggest ineffective coping, as the patient struggles to process missing a treatment. Psychiatric evaluation can assess underlying emotional distress, such as anxiety or depression, and provide targeted interventions, making this the correct choice for addressing the patient’s needs.

Choice B reason: Symptoms like withdrawal could suggest depression, but diagnosing major depressive disorder requires more criteria, such as persistent low mood or anhedonia, not evident here. Immediate intervention assumes severity not supported by the scenario, making this choice less accurate than a referral.

Choice C reason: Labeling the patient as noncompliant assumes intentional refusal, but the scenario suggests emotional distress, not deliberate nonadherence. Withdrawal and avoidance indicate psychological barriers, not noncompliance, making this choice incorrect for the described behavior.

Choice D reason: Normal grief involves stages like denial or sadness, but the scenario lacks evidence of a loss triggering grief. Withdrawal and avoidance suggest coping difficulties, not a clear grief process, making this choice incorrect for the patient’s presentation.

A. Apply restraints and leave the patient unattended for 2 hours B. Restrain the patient to the bed using all four limbs tightly to limit any movement C. Ensure a provider’s face-to-face evaluation occurs within 1 hour of restraint application D. Document the restraint use once at the end of the shift

Correct Answer is C

Explanation

Choice A reason: Leaving a restrained patient unattended for 2 hours violates safety standards, as restraints pose risks like injury or respiratory compromise. Regular monitoring is required to assess circulation, skin integrity, and psychological distress, ensuring patient safety, making this choice incorrect.

Choice B reason: Restraining all four limbs tightly risks injury, such as nerve damage or impaired circulation, and violates least-restrictive restraint principles. Restraints should allow minimal movement and be applied only as necessary, with regular reassessment, making this choice incorrect.

Choice C reason: A provider’s face-to-face evaluation within 1 hour is required by regulations to ensure restraints are justified and safe. This assesses the patient’s condition, mental status, and need for continued restraint, minimizing harm and ensuring compliance, making this the correct choice.

Choice D reason: Documenting restraint use only at shift’s end is inadequate, as regulations require ongoing documentation of restraint rationale, patient condition, and monitoring. Delayed documentation risks missing critical changes, compromising care and legal compliance, making this choice incorrect.

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An elderly patient with advanced Alzheimer’s disease is admitted to the unit. The nurse is informed that the patient has a court-appointed legal guardian. The guardian arrives and asks for information about the patient’s medications and plan of care. What is the nurse’s best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient missed a treatment option. Later, the patient appears withdrawn and avoids eye contact when discussing calling loved ones. Which is the best nursing action?

Correct Answer is A

Explanation

A patient becomes agitated and physically aggressive on the unit, requiring the use of restraints. Which of the following actions by the nurse is appropriate when applying and managing restraints?

Correct Answer is C

Explanation

A patient diagnosed with schizophrenia tells the nurse, “I hear voices sometimes, but they don’t bother me.” Which of the following is the most appropriate open-ended response by the nurse to further assess the patient’s experience?

A nurse observes a patient with bipolar disorder who suddenly shifts from laughing joyfully to crying within minutes during the therapy session. This sudden and intense change in emotional expression is an example of:

A woman experiences deep sadness after the death of her “side-piece,” but she feels unable to openly mourn because their relationship was not recognized openly. The nurse identifies this as an example of:

A nurse is caring for a patient diagnosed with schizophrenia. During the interaction, the nurse notices that the patient’s facial expressions are minimal and do not seem to match the emotions being expressed verbally. This is an example of:

What is psychomotor retardation as seen in psychiatric patients?

An elderly patient with advanced Alzheimer’s disease is admitted to the unit. The nurse is informed that the patient has a court-appointed legal guardian. The guardian arrives and asks for information about the patient’s medications and plan of care. What is the nurse’s best response?

During a psychiatric assessment, a patient frequently shifts from one topic to another and never returns to the original question asked by the nurse. This pattern of speech is best described as:

A patient is brought to the psychiatric unit by family members after expressing suicidal thoughts but refuses voluntary admission. The healthcare team proceeds with involuntary commitment. Which of the following statements best describes involuntary commitment?