A charge nurse is supervising a newly licensed nurse who is caring for a client who is experiencing auditory hallucinations and is refusing medication. The newly licensed nurse suggests placing the medication in the client's food to the charge nurse. Which of the following actions should the charge nurse take?

Suggest the family persuade the client to take the medication.

Recommend that the medication be delivered intramuscularly.

Remind the newly licensed nurse that the client has a right to refuse medication.

Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods.

Answer and Explanation

The Correct Answer is C

The charge nurse should remind the newly licensed nurse that the client has a right to refuse medication. It is important for healthcare providers to respect the autonomy and rights of their clients, including the right to refuse treatment.

Option a is incorrect because it may not be appropriate for the family to persuade the client to take medication against their wishes.

Option b is incorrect because delivering medication intramuscularly against the client's wishes would violate their right to refuse treatment.

Option d is incorrect because inquiring about compatible foods with the pharmacy would not address the issue of the client's right to refuse medication.

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Correct Answer is B

Explanation

b. "You can use an adhesive remover when changing the colostomy skin barrier."

The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.

Explanation for the other options:

a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.

c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.

d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.

A. Frequently remind the client of the expectations for her behavior. B. Encourage the client to participate in a group activity in the dayroom. C. Allow the client to pick her own choice of clothing. D. Encourage the client to increase physical activity during the day.

Correct Answer is A

Explanation

Answer: A. Frequently remind the client of the expectations for her behavior.

Rationale:

A) Frequently remind the client of the expectations for her behavior:

Clients experiencing mania may have difficulty maintaining appropriate behavior due to their heightened energy levels and impulsivity. Frequently reminding them of behavioral expectations helps provide structure and boundaries, which can promote a safer and more controlled environment.

B) Encourage the client to participate in a group activity in the dayroom:

While social interaction can be beneficial, clients in a manic state might be overly stimulated by group activities. This can exacerbate their symptoms, leading to increased agitation or disruptive behavior. It's often more appropriate to provide a calm and low-stimulation environment.

C) Allow the client to pick her own choice of clothing:

Allowing a manic client to choose their own clothing can lead to choices that are inappropriate for the setting or the weather, as judgment may be impaired during mania. Providing guidance in clothing choices can help ensure the client is dressed suitably and safely.

D) Encourage the client to increase physical activity during the day:

While physical activity is generally beneficial, clients in a manic state may already be overly active and may not need encouragement to increase their activity. Overexertion can lead to exhaustion and further exacerbate manic symptoms. It is often more beneficial to encourage activities that promote relaxation and calmness.

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A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Correct Answer is B

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Correct Answer is A

Explanation

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