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 C

Explanation

A. Weigh the client every 48 hr. – Clients with anorexia nervosa should be weighed daily at the same time to monitor for fluctuations in weight and refeeding complications.

B. Allow the client to eat meals in his room. – Clients should eat meals in a monitored dining area to prevent food hoarding, purging, or avoidance of meals.

C. Observe the client for 1 hr after meals. – This is the correct answer because clients with anorexia nervosa are at risk of purging or excessive exercise after meals. Close observation helps prevent these behaviors.

D. Obtain the client’s vital signs every other day. – Vital signs should be monitored daily or more frequently if the client is medically unstable.

A. "Would you tell me more about the changes you see in your body?" B. "How long have you had these feelings of uselessness? C. "Did anything in particular make you feel this way? D. "Do you ever think about harming yourself?"

Correct Answer is D

Explanation

A. Asking about body changes is important for understanding the client’s self-perception, but it does not address immediate safety concerns.

B. Inquiring about the duration of feelings of uselessness is helpful for assessing depressive symptoms, but it is not the priority over assessing for suicidal intent.

C. Exploring triggers for these feelings is useful for emotional support and planning interventions but is secondary to assessing for immediate risk of self-harm.

D. This question assesses for suicidal ideation, which is the nurse’s priority because older adults experiencing feelings of uselessness or hopelessness are at higher risk for depression and suicide. Early identification of suicidal thoughts ensures prompt intervention and support.

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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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Naxlex Comprehensive Predictor Exams

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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