The healthcare provider prescribes haloperidol 10 mg for a client with severe psychosis, but the client refuses the medication. Which initial nursing action is appropriate?

Restrain the client and give the medication intramuscularly

Inform the client that refusing the medication means not getting any better

Accept the client’s decision and continue to maintain safety

Obtain a discharge order for nonadherence to the medication regimen

Answer and Explanation

The Correct Answer is C

Choice A reason: Restraining and forcibly administering medication violates patient autonomy and ethical principles, potentially escalating agitation in psychosis. It risks physical harm and legal issues, as forced medication requires specific legal orders (e.g., involuntary commitment). Non-invasive approaches like negotiation or assessing refusal reasons are safer and more ethical.

Choice B reason: Stating that refusal prevents improvement is coercive and undermines autonomy. It fails to explore reasons for refusal, such as side effect concerns or psychosis-related mistrust, which are common in severe psychosis. This approach may damage trust and hinder therapeutic alliance, making it inappropriate as an initial action.

Choice C reason: Accepting the client’s refusal respects autonomy while prioritizing safety, critical in psychosis where agitation is common. This allows exploration of refusal reasons (e.g., paranoia) and alternative interventions, maintaining a therapeutic environment. Monitoring ensures no immediate harm, making this the most ethical and safe initial response.

Choice D reason: Obtaining a discharge order for nonadherence is premature and inappropriate, as refusal does not warrant immediate discharge. Psychosis requires ongoing assessment and management, and discharge could exacerbate symptoms or risk harm, making this action contrary to the goal of stabilizing the client’s mental health.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: While behavior acceptability varies across cultures, this statement does not fully define mental health or illness. Cultural norms influence behavior interpretation, but mental health involves emotional and psychological well-being, not just cultural acceptability, making this option incomplete as a definition of mental health or illness.

Choice B reason: Mental health is characterized by emotional, psychological, and social well-being, reflected in adaptive coping strategies like problem-solving or seeking support. This holistic state enables individuals to manage stress and function effectively, making this statement a comprehensive and accurate description of mental health in contrast to mental illness.

Choice C reason: Engaging in fantasies is not inherently indicative of mental illness, as it can be a normal part of creativity or coping. Only when fantasies disrupt functioning or reflect delusions does it suggest illness. This statement is inaccurate, as it overgeneralizes a common behavior as pathological.

Choice D reason: Determining mental health or illness via verbal and nonverbal communication is complex and not always reliable. Cultural, individual, and contextual factors obscure interpretation, and clinical assessment requires comprehensive evaluation beyond communication, making this statement inaccurate as a definitive method for assessing mental health status.

A. Apologize for asking such a personal and intrusive question B. Encourage the client to make a list of their concerns and offer to discuss it with them on how to cope with homelessness C. Divert the subject to something the client will readily discuss D. Sit quietly allowing the client time to process before responding

Correct Answer is D

Explanation

Choice A reason: Apologizing for the question may imply it was inappropriate, undermining the therapeutic intent to explore emotions. Homelessness is a valid topic in mental health care, and apologizing could discourage further discussion, disrupting trust and the client’s ability to process and express difficult emotions.

Choice B reason: Encouraging a list of concerns shifts focus to problem-solving prematurely, potentially overwhelming the client who is processing emotions. This action disregards the client’s need for reflection, which is critical in therapeutic communication to facilitate emotional expression and address underlying psychological distress effectively.

Choice C reason: Diverting the subject avoids the client’s emotional response, missing a therapeutic opportunity to explore feelings about homelessness. This can signal discomfort with the topic, reducing trust and hindering the client’s ability to process trauma, which is essential for mental health recovery and coping.

Choice D reason: Sitting quietly allows the client time to process complex emotions about homelessness, fostering a safe therapeutic environment. Silence supports reflection, enabling the client to articulate feelings at their pace, which enhances trust and facilitates deeper emotional exploration, making it the most therapeutic response in this context.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The healthcare provider prescribes haloperidol 10 mg for a client with severe psychosis, but the client refuses the medication. Which initial nursing action is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is true regarding mental health and mental illness?

Correct Answer is B

Explanation

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

Correct Answer is D

Explanation

The nurse is evaluating clients in the emergency department (ED) for pending mental health admissions. Which client will be admitted for involuntary hospitalization?

Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

A nurse working on a psychiatric unit receives a telephone call from a client’s employer requesting a copy of the client’s psychological evaluation results. Based on the nurse’s knowledge of breach of confidentiality, which response would be appropriate?

The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

The nurse is sitting down with a client to begin a conversation. Which position will the nurse take to convey acceptance of the client?

A client with a history of chronic renal failure receives hemodialysis treatment three times per week through an arteriovenous (AV) fistula in the left arm. Which priority intervention should the nurse include in the care plan?

Morphine sulfate 10 mg IV is prescribed. Available 4 mg/mL How many mL be given?

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, “What if I encounter a client who is sexually aggressive?” Which is the appropriate response by the preceptor?