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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Visitors are not completely prohibited, but their time should be limited and precautions followed, especially for children and pregnant individuals. Therefore, banning all visitors for 24 hours is unnecessary and overly restrictive.
B. Maintaining a distance of at least 3 feet from the radiation source helps reduce exposure, following the principle of distance in radiation safety. This is an appropriate and effective protective measure for the nurse.
C. Bed rest is typically required to prevent displacement of the sealed radiation device, but it is not specifically prescribed for a fixed duration like 72 hours. The duration depends on the treatment plan, so this statement is too rigid and not universally correct.
D. Dosimeter badges are worn by healthcare workers to measure occupational exposure, not by clients receiving radiation therapy. Therefore, this action is inappropriate for the client.
Correct Answer is D
Explanation
A. Insisting the client use direct eye contact may be intimidating or uncomfortable for the client, especially in a mental health setting where individuals may have varying levels of comfort with eye contact.
B. Seating the client at such a distance may create a physical barrier and hinder effective communication between the nurse and the client.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially during a sensitive interview.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and facilitates a sense of closeness and engagement in the conversation, which can help build rapport and trust.
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