A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
Stop the car in the client's driveway and call the authorities.
Honk the car horn to get the client's attention.
Calmly speak the client's name out of the car window.
Keep driving in a path that is going away from the client's house.
The Correct Answer is D
Choice A reason:
Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.
Choice B reason:
Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.
Choice C reason:
Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.
Choice D reason:
Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Supporting the client's wish to refuse prescribed medications is a direct demonstration of respecting the client's autonomy. Autonomy in nursing is the right to self-determination, where patients are provided with adequate information to make their own decisions based on their beliefs and values. By supporting the client's decision, the nurse acknowledges the client's capacity to make informed choices about their own health care, even if the choice is different from what the medical team suggests.
Choice B Reason:
Ensuring that the client understands expectations for participation is more about informed consent and education rather than autonomy. While it is related to autonomy, it does not directly demonstrate the ethical concept since it does not involve a decision made by the client.
Choice C Reason:
Explaining unit rules and policies about unacceptable behaviors is part of the education process and setting boundaries within the healthcare environment. This action is necessary for all clients but does not specifically address the client's autonomy in making personal health decisions.
Choice D Reason:
Encouraging client feedback about satisfaction with the facility experience is a way to involve clients in the evaluation process of the facility's services. While this can be seen as respecting the client's opinions, it is not a direct action of supporting the client's autonomous decisions regarding their treatment plan
Correct Answer is C
Explanation
Choice A reason:
Bleeding is not commonly associated with the use of haloperidol. While antipsychotic medications can have a wide range of side effects, bleeding is not typically reported as an adverse effect of haloperidol.
Choice B reason:
Pancreatitis is not a recognized adverse effect of haloperidol. This condition involves inflammation of the pancreas and is more commonly associated with medications that affect the gastrointestinal system directly.
Choice C reason:
Dysrhythmias, or abnormal heart rhythms, are known adverse effects of haloperidol. This medication can affect the electrical activity of the heart, potentially leading to serious cardiac events.
Choice D reason:
Cataracts are not a direct adverse effect of haloperidol. While long-term use of some medications can increase the risk of developing cataracts, haloperidol is not specifically linked to this condition.
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