A 45-year-old client with severe schizophrenia is deemed incapable of making informed decisions about their treatment due to cognitive impairment and psychosis. The healthcare team recommends appointing a legal guardian. As the nurse, which of the following actions is most appropriate to support the client’s rights and care during this process?
Collaborate with the healthcare team and family to ensure the guardian acts in the client’s best interest while advocating for the client’s preferences.
Explain to the client that they will have limited control over their treatment decisions once the guardian is appointed.
Omit communication with the client until legal guardianship is finalized to avoid confusion.
Immediately initiate treatment without client consent once guardianship is recommended.
The Correct Answer is A
Choice A reason: The nurse’s role is to advocate for the client by collaborating with the healthcare team and ensuring the guardian respects the client’s best interests and personal preferences. This balances autonomy and protection.
Choice B reason: While explaining changes in decision-making is part of education, focusing only on the loss of control without emphasizing advocacy may increase fear and distress.
Choice C reason: Avoiding communication violates therapeutic principles and disregards the client’s dignity. Even if incapable of informed consent, clients should remain included in discussions.
Choice D reason: Treatment cannot proceed without proper consent unless there is an emergency. Acting before guardianship is finalized would violate legal and ethical standards.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Sedative medications may be used in severe cases, but immediate nursing care focuses on nonpharmacologic interventions to ensure safety and reduce stimulation. Medication is not the first-line action.
Choice B reason: Providing a calm environment with reduced external stimuli while encouraging expression of feelings helps the client regain control and decreases anxiety during a panic episode. This is the most appropriate nursing intervention.
Choice C reason: Detailed problem-solving requires higher-level cognitive functioning, which is impaired during a panic attack. Attempting this intervention may increase the client’s distress.
Choice D reason: Allowing expression without guidance offers no therapeutic support and may leave the client overwhelmed by panic symptoms, prolonging the episode.
Correct Answer is C
Explanation
Choice A reason: While silence may sometimes convey understanding, its primary therapeutic purpose in communication is to allow the patient time to think or reflect, not simply to indicate understanding.
Choice B reason: Prolonged silence may cause withdrawal in some patients, but this is not the guiding principle in therapeutic communication. The focus should be on the value of reflection.
Choice C reason: Silence provides the patient with opportunities for reflection and processing of thoughts and emotions. It encourages deeper expression and supports therapeutic dialogue.
Choice D reason: The nurse is not always responsible for breaking silence. Sometimes allowing the patient to break the silence themselves is more therapeutic and empowering.
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