A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

Explain to the client the consequences of refusal.

Identify the reason for the client's refusal.

Document the client's refusal in the medical record.

Inform the provider of the client's refusal.

Answer and Explanation

The Correct Answer is B

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

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Correct Answer is A

Explanation

A. Inserting an indwelling catheter is within the scope of practice for an LPN and requires technical skill and training that an LPN possesses. This task is appropriate for delegation because it does not require the RN's direct clinical judgment or assessment at the time of insertion. The LPN can perform this procedure based on a specific directive from the RN.
B. Obtaining the abdominal girth is a task that involves assessment and this cannot be delegated by the RN to an LPN.

C. Assessing and documenting the level of consciousness involves critical thinking and

interpretation of assessment findings, making it more appropriate for the registered nurse to perform.

D. Measuring gastric drainage is a task that the LPN can perform, but it is less critical compared to the insertion of an indwelling catheter in this scenario. The RN should prioritize delegating tasks to the LPN that require their specific skills, such as catheter insertion, while reserving simpler tasks for the AP.

A. Constipation B. Indigestion C. Swollen ankles D. Urinary frequency E. None F. None

Correct Answer is B

Explanation

A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.

B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.

C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."

D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.

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A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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