A newly licensed nurse is assisting with the involuntary admission of a client who has depression to an acute care mental health facility. Which of the following guidelines should the nurse follow when caring for the client?
The client can undergo electroconvulsive therapy without giving informed consent.
The nurse can share information with the client's family without his permission.
The client has the right to refuse medication.
The nurse may use restraints as needed (PRN).
The Correct Answer is C
Choice A reason: Electroconvulsive therapy (ECT) requires informed consent, as it is a significant medical procedure involving anesthesia and induced seizures. Informed consent is a process where a patient is fully informed about the procedures and risks involved in a treatment and voluntarily agrees to it.
Choice B reason: Nurses cannot share information with a client's family without the client's permission due to confidentiality laws, except in specific circumstances defined by law. Patient information is protected under the Health Insurance Portability and Accountability Act (HIPAA), which requires patient consent for disclosure.
Choice C reason: Patients have the right to refuse medication. This right is part of the patient's autonomy and informed consent process. A mentally competent adult can refuse treatment, even if it may result in serious illness or death.
Choice D reason: The use of restraints in mental health facilities is highly regulated. Restraints may only be used when necessary to prevent immediate harm to the patient or others and must be discontinued as soon as the risk of harm has subsided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Respiratory alkalosis is typically associated with hyperventilation, which is not common in acute pulmonary edema.
Choice B reason: Metabolic acidosis can occur in pulmonary edema due to tissue hypoxia and lactic acid production, but respiratory acidosis is more directly related to the primary problem of gas exchange.
Choice C reason: Respiratory acidosis is likely in acute pulmonary edema due to impaired gas exchange and CO2 retention.
Choice D reason: Metabolic alkalosis is not typically associated with acute pulmonary edema and is less likely than respiratory acidosis in this context.
Correct Answer is A
Explanation
Choice A reason: A rapid weight gain is a common sign of fluid retention, which can indicate an exacerbation of heart failure.
Choice B reason: Being able to breathe easier would typically indicate an improvement in heart failure symptoms, not an exacerbation.
Choice C reason: Cooking dinner suggests a level of activity that is not indicative of an exacerbation of heart failure.
Choice D reason: The absence of swelling in the feet would generally be a positive sign, not indicative of an exacerbation of heart failure.
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