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 D

Explanation

- A) Utility: This principle is about producing the greatest good for the greatest number. In the case of a medication error, the focus is not on the collective good but on the individual patient's rights and well-being.
- B) Paternalism: This principle involves making decisions for others, potentially against their will, for their own good. It does not directly apply to the situation of a medication error where the patient's autonomy and right to be informed are paramount.
- C) Fidelity: This principle refers to loyalty and keeping one's promises. While important, it is secondary to the immediate need for honesty and transparency in the event of a medication error.
- D) Veracity: This principle obligates healthcare providers to tell the truth. When a medication error occurs, it is crucial to inform the patient about the mistake and the steps being taken to remedy it, making veracity the most applicable ethical principle in this scenario.

A. Head circumference 1 cm greater than chest B. Positive Babinski reflex on bilateral feet C. Passage of meconium stool D. Pinna below the outer canthus of the eye

Correct Answer is D

Explanation

A. A head circumference 1 cm greater than the chest is within normal variations and does not typically require immediate notification.

B. A positive Babinski reflex is a normal finding in newborns and does not warrant immediate notification.

C. Passage of meconium stool within the first 24 hours of life is considered normal and does not require notification.

D. The pinna (ear) below the outer canthus of the eye can indicate a condition called low-set ears, which may be associated with genetic syndromes or other abnormalities. This finding warrants notification to the provider for further evaluation.

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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

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Correct Answer is D

Explanation

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