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 C

Explanation

A. A flat anterior fontanel can indicate dehydration in infants, so this finding does not indicate effective treatment.

B. Oliguria, or decreased urine output, is a sign of dehydration and would not indicate effective treatment.

C. Oral intake of 4 oz every 3 hours indicates that the infant is able to drink fluids and is likely rehydrated, indicating effective treatment.

D. A capillary refill of 4 seconds is prolonged and can indicate poor perfusion, which is not indicative of effective treatment for dehydration.

A. Perform active range-of-motion exercises. B. Maintain the head at a midline position. C. Suction the airway frequently. D. Perform neurological checks every 4 hours.

Correct Answer is B

Explanation

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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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 is caring for an infant who is being treated for dehydration. Which of the following findings indicates the treatment is effective?

Correct Answer is C

Explanation

A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective?

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

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A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)