A nurse is caring for a client following an involuntary admission to'an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make?

"You will need to rest so that you can recover from the episode that brought you here."

"I will make sure that we respect your right to refuse medications.

"It's not your choice to be here, so you have to accept the treatment we plan for you."

"Why do you think your provider will prescribe you medications that will make you sleep?"

Answer and Explanation

The Correct Answer is B

A. "You will need to rest so that you can recover from the episode that brought you here.": This response dismisses the client's fear and does not address their concern about being given medications that induce sleep. It also does not acknowledge the client's right to refuse medications or address their autonomy.
B. "I will make sure that we respect your right to refuse medications.": This response validates the client's concern and reassures them that their autonomy and right to refuse medications will be respected. It promotes trust and therapeutic communication between the nurse and the client.
C. "It's not your choice to be here, so you have to accept the treatment we plan for you.": This response undermines the client's autonomy and rights, which can erode trust and impede therapeutic rapport. Involuntary admission does not negate the client's right to participate in treatment decisions or refuse medications.
D. "Why do you think your provider will prescribe you medications that will make you sleep?": This response challenges the client's perception and may come across as confrontational. It does not address the client's fear or provide reassurance about their rights regarding medication administration.

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Correct Answer is B

Explanation

A. Performing a simple dressing change on a client's foot - This action is appropriate and within the scope of practice for assistive personnel.
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile - Handwashing with alcohol-based hand rub is not effective against Clostridium difficile spores. Proper hand hygiene for C. difficile requires washing with soap and water. The charge nurse should intervene to correct this action and ensure proper infection control procedures are followed.
C. Providing postmortem care for a client who has recently died - Providing postmortem care is within the scope of practice for assistive personnel and is appropriate.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves - This action is appropriate and within the scope of practice for assistive personnel.

A. Loss of central vision B. Increased intraocular pressure C. Decrease in peripheral vision D. A bluish-white colored pupil

Correct Answer is D

Explanation

A. Loss of central vision: While loss of central vision can occur with various eye conditions, such as age-related macular degeneration, it is not specific to cataracts. Cataracts typically cause clouding of the lens, leading to blurred or dimmed vision rather than loss of central vision.
B. Increased intraocular pressure: Increased intraocular pressure is characteristic of conditions such as glaucoma, not cataracts. Cataracts involve clouding of the lens rather than elevated pressure within the eye.
C. Decrease in peripheral vision: Decreased peripheral vision is associated with conditions like retinitis pigmentosa or glaucoma but is not a typical finding in cataracts. Cataracts primarily affect visual acuity and clarity rather than peripheral vision.
D. A bluish-white colored pupil: A bluish-white appearance of the pupil, known as leukocoria or a white pupil reflex, can be indicative of cataracts. It occurs due to light scattering by the cloudy lens of the eye, resulting in an abnormal reflection from the pupil. This finding is characteristic of cataracts and warrants further evaluation by an ophthalmologist.

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A nurse is caring for a client following an involuntary admission to'an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make?

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Correct Answer is B

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Correct Answer is D

Explanation

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