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?

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

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

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

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

Answer and Explanation

The Correct Answer is A

A. "I will make sure that we respect your right to refuse medications." – This response respects the client's autonomy and reassures them that their rights will be upheld.

B. "You will need to rest so that you can recover from the episode that brought you here." – This statement dismisses the client's concerns rather than addressing them.

C. "Why do you think your provider will prescribe you medications that will make you sleep?" – While open-ended questions can encourage discussion, this does not directly reassure the client about their rights.

D. "It's not your choice to be here, so you have to accept the treatment we plan for you." – This statement is inappropriate and disregards the client's legal rights.

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Correct Answer is A

Explanation

A. A child who has acute epiglottitis and is drooling – This is the priority because drooling, stridor, and respiratory distress suggest airway obstruction, which is life-threatening. Immediate intervention is required to secure the airway.

B. A child who has a urinary tract infection and bright red blood in her urine – Hematuria can be concerning but is not immediately life-threatening.

C. A child who has mononucleosis and reports severe fatigue – Fatigue is common with mononucleosis but does not require immediate intervention.

D. A child who has Wilms' tumor and an abdominal mass – While Wilms' tumor is serious, it does not present an immediate airway or hemodynamic emergency.

A. Temperature B. Respiratory rate C. SpO2 D. pH

Correct Answer is C

Explanation

A. Temperature: 37.2°C (99.0°F) is within the normal range.

B. Respiratory rate: 28/min is elevated but expected in COPD.

C. An SpO₂ of 88% indicates significant hypoxemia in a client with COPD, which requires immediate intervention. Oxygen therapy may be needed to maintain a target saturation of 88–92%.

D. pH: 7.22 indicates respiratory acidosis but is consistent with COPD and requires monitoring rather than immediate notification.

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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?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is C

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