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 B

Explanation

A. Rearrange furniture to clear walkways – While important for fall prevention, it does not directly address medication safety.

B. Use container lids of different shapes to indicate times of administration – Correct. Using distinct tactile markers helps clients with vision loss distinguish medications and adhere to their regimen.

C. Cover appliance cords with throw rugs – Incorrect. Throw rugs are a tripping hazard and should be removed, not used to cover cords.

D. Visit the client once per month to assess medication usage – Monthly visits may not be sufficient for ensuring medication adherence and safety.

A. Sore throat B. Blood-tinged mucus C. Frequent swallowing D. Dark brown emesis

Correct Answer is C

Explanation

A. Sore throat – A sore throat is expected following a tonsillectomy due to the surgical site trauma. It is not an immediate concern unless accompanied by other abnormal findings such as severe pain or difficulty breathing.

B. Blood-tinged mucus – Small amounts of blood-tinged mucus are normal after surgery. However, active bleeding would present as bright red blood rather than a small amount of tinged mucus.

C. Frequent swallowing – This is the priority finding because it may indicate active bleeding at the surgical site. Children may not always report bleeding but may swallow frequently as blood drips into their throat. If left undetected, excessive bleeding can lead to hemorrhage and airway compromise. The nurse should inspect the throat immediately and notify the provider.

D. Dark brown emesis – Vomiting old blood (which appears dark brown) may occur if the child swallowed some blood postoperatively. While this should be monitored, it is not as concerning as active bleeding, which presents as bright red blood.

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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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A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day. Which of the following actions should the nurse include in the plan?

Correct Answer is B

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Correct Answer is C

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