A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?

Delay the admission while the client fills out the facility’s advance directives form.

Confirm with the client’s family that the consent form has been signed.

Explain to the client that signing the facility’s consent form means they cannot refuse care.

Determine if the client has prepared their advance directives.

Answer and Explanation

The Correct Answer is D

The nurse should determine if the client has prepared their advance directives, which are legal documents that specify the client’s wishes regarding medical care in case they become incapacitated. Advance directives can include a living will, a durable power of attorney for health care, or a do-not-resuscitate order. The nurse should respect the client’s autonomy and right to self-determination by asking about their advance directives and ensuring that they are documented and followed.

Choice A is wrong because the nurse should not delay the admission while the client fills out the facility’s advance directives form.

The client has the right to refuse or accept any treatment, including filling out an advance directives form.

The nurse should inform the client about the benefits of having advance directives, but should not coerce or pressure them to complete one.

Choice B is wrong because the nurse should not confirm with the client’s family that the consent form has been signed.

The consent form is a legal document that indicates that the client has given informed consent for the surgery, which means that they have received adequate information about the procedure, its risks and benefits, and alternative options.

The consent form should be signed by the client, unless they are a minor, mentally incompetent, or unable to communicate.

The nurse should verify that the consent form has been signed by the client or their legal representative before the surgery.

Choice C is wrong because the nurse should not explain to the client that signing the facility’s consent form means they cannot refuse care.

Signing the consent form does not waive the client’s right to withdraw consent at any time before or during the surgery.

The nurse should inform the client that they can change their mind and refuse care at any point, and that their decision will be respected and honored.

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Correct Answer is ["B","C","E"]

Explanation

Correct Answers:Distractibility. Grandiose thinking. Flight of ideas.

These are the common symptoms of mania in bipolar disorder.

Some possible explanations for the other choices are:

Choice A is wrong because anhedonia, which means loss of interest or pleasure in activities, is a symptom of depression, not mania.
Choice D is wrong because overeating is not a specific symptom of mania, although some people with bipolar disorder may have changes in appetite or weight during mood episodes.

A. Warn the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination. B. Keep the facility’s security personnel constantly visible to the client throughout treatment. C. Collaborate with the client to develop a daily physical exercise routine. D. Agree that the hallucinations are real if the client exhibits aggressive behavior toward other clients.

Correct Answer is C

Explanation

Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.

Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.

Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.

Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.

The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.

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A nurse is assisting with the admission of a client who is scheduled for surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has bipolar disorder and is exhibiting manifestations of mania. Which of the following findings should the nurse expect? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

A nurse is contributing to the plan of care for a newly-admitted client who has schizophrenia and a history of aggressive behavior. Which of the following interventions should the nurse include in the initial plan?

Correct Answer is C

Explanation

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