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?
"It's not your choice to be here, so you have to accept the treatment we plan for you.”
"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?”
"I will make sure that we respect your right to refuse medications.”
The Correct Answer is D
Choice A rationale:
Telling the client, "It's not your choice to be here, so you have to accept the treatment we plan for you," disregards the client's autonomy and right to make decisions about their own healthcare. In mental health settings, respecting a patient's autonomy and involving them in the decision-making process is crucial for ethical care. This statement does not address the client's fear or provide any reassurance.
Choice B rationale:
Choice C rationale:
Asking, "Why do you think your provider will prescribe you medications that will make you sleep?" attempts to explore the client's fear, but it may come across as dismissive or invalidating. It could make the client feel unheard or misunderstood, which is not ideal in this situation.
Choice D rationale:
Stating, "I will make sure that we respect your right to refuse medications," is the most appropriate response. It acknowledges the client's fear and reassures them that their autonomy will be respected. It opens the door for a discussion about the client's concerns, allowing them to express their fears and preferences. Respecting the client's right to refuse medications is fundamental to ethical nursing practice and patient-centered care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
- A. This choice is incorrect because an older adult client who reports constipation of 4 days is not an urgent situation that requires immediate attention. The nurse should assess the client's hydration status, bowel habits, and medication use, and provide education on dietary and lifestyle modifications to prevent constipation.
- B. This choice is incorrect because a preschooler who has a skin rash is not an urgent situation that requires immediate attention. The nurse should assess the type, location, and distribution of the rash, as well as any history of allergies, exposure, or infection, and provide appropriate treatment and education.
- C. This choice is incorrect because an adolescent who has a closed fracture is not an urgent situation that requires immediate attention. The nurse should assess the site of injury, neurovascular status, pain level, and immobilization device, and provide analgesia and education on fracture care.
- D. This choice is correct because a middle adult client who has unstable vital signs is an urgent situation that requires immediate attention. The nurse should assess the client's level of consciousness, airway, breathing, circulation, and possible causes of instability, and initiate lifesaving interventions.
Correct Answer is C
Explanation
Choice A rationale:
A random plasma glucose level of 176 mg/dL indicates high blood sugar at the time of the test. Random glucose levels are not ideal for assessing glycemic control as they can vary based on recent food intake and stressors.
Choice B rationale:
Triglyceride levels are not used to assess glycemic control. They measure the amount of triglycerides in the bloodstream and are related to lipid metabolism, not glucose control.
Choice C rationale:
HbA1c (glycated hemoglobin) is a long-term measure of blood glucose control. An HbA1c level of 6.8% indicates acceptable glycemic control in a person with diabetes. The normal range for HbA1c is typically less than 6.5%. This test reflects the average blood sugar level over the past 2-3 months, giving a better understanding of overall glucose control.
Choice D rationale:
Fasting blood glucose of 120 mg/dL is slightly elevated. While fasting blood glucose levels below 100 mg/dL are generally considered normal, levels between 100-125 mg/dL are considered prediabetic, and levels above 126 mg/dL on two separate occasions indicate diabetes. The result provided falls within the prediabetic range but does not indicate optimal glycemic control.
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