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: Telling the patient to stop thinking a certain way invalidates their feelings and is not therapeutic.
Choice B reason: Offering presence and calm support provides safety and helps reduce anxiety. It is the most therapeutic intervention for severe anxiety.
Choice C reason: Telling the patient not to worry may feel dismissive, and in severe anxiety the patient may not be able to process reassurance.
Choice D reason: Asking "why" is not effective when the patient is overwhelmed by severe anxiety, as they cannot engage in rational discussion at that moment.
Correct Answer is B
Explanation
Choice A reason: Haloperidol may be used for severe agitation or hallucinations but is not the first-line treatment for delirium tremens because it does not address the underlying withdrawal process.
Choice B reason: Lorazepam, a benzodiazepine, is the drug of choice for managing alcohol withdrawal and delirium tremens. It reduces agitation, prevents seizures, and manages autonomic instability.
Choice C reason: Naltrexone is used to reduce alcohol cravings and prevent relapse but is not appropriate for acute withdrawal or delirium tremens.
Choice D reason: Disulfiram is an aversive therapy medication used to discourage alcohol consumption by causing unpleasant effects if alcohol is ingested. It is contraindicated during withdrawal due to safety risks.
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