A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist.

The nurse throws the medication in the trash and documents the client refuses the medication.

The nurse pushes the client, and the client falls to the floor and sustains a nosebleed.

The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth.

Answer and Explanation

The Correct Answer is D

Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.

Options A, B, and C are not examples of false imprisonment:

A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.

B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.

C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.

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Correct Answer is C

Explanation

When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.

Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.

The other options are not appropriate for the following reasons:

A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.

B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.

D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.

A. Accept the client's decision and continue to maintain safety. B. Obtain a discharge order for nonadherence to the medication regimen. C. Restrain the client and give the medication intramuscularly. D. Inform the client that refusing the medication means not getting any better.

Correct Answer is A

Explanation

Every individual has the right to refuse medical treatment, including medications, as long as they are competent to make that decision. It is essential to respect the client's autonomy and right to make decisions about their own health care. When a client refuses medication, the nurse should document the refusal, inform the healthcare provider, and explore the reasons behind the refusal if possible.

The other options are not appropriate for the following reasons:

B- Obtaining a discharge order for nonadherence: While it is essential to address nonadherence to medication, discharging the client solely for refusing the medication may not be the best course of action. Instead, the nurse should work collaboratively with the healthcare team to address the client's concerns and explore alternative treatment options.

C- Restraining the client and giving the medication intramuscularly: Restraints should only be used as a last resort when a client presents an imminent danger to themselves or others, and it must be done in accordance with facility policies and legal regulations. Using restraints to administer medication against a client's will is a violation of their rights and is not an appropriate response to medication refusal.

D-Informing the client that refusing the medication means not getting any better: This response may be seen as coercive and manipulative. It is not ethical to use fear or guilt to persuade a client to take medication against their will. Instead, the nurse should provide information about the potential benefits and risks of the medication and address the client's concerns or fears about the treatment. Ultimately, the decision to take the medication should be left to the client after they have been fully informed about their options.

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A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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