A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr. after attacking a neighbor.
To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?
Whether the client is unable to make arrangements to stay with someone.
Whether the client is financially incapable of paying for medications.
Whether the client is in danger of harming herself or others.
Whether the client is unwilling to accept that treatment is needed.
The Correct Answer is C
Involuntary admission to a mental health unit is done when an individual poses a threat to themselves or others due to a mental health condition. The initial hold is usually for 72 hours, during which the client's condition is assessed and an appropriate treatment plan is developed. If the client is still deemed to be a danger to themselves or others after the initial hold, the healthcare provider may request an extension of the hold or seek a court order to continue treatment.
In order to keep the client in the hospital, it must be determined that they continue to pose a threat to themselves or others.
Factors such as the client's ability to make arrangements to stay with someone or financial capability to pay for medications are not relevant to the decision of whether to continue the hold.
Similarly, unwillingness to accept treatment is not the determining factor, as involuntary treatment can be provided to clients who do not recognize their need for treatment if they are deemed to be a danger to themselves or others.
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Related Questions
Correct Answer is A
Explanation
Breach of confidentiality occurs when private and sensitive information is disclosed to others without the client's consent. In this scenario, the co-workers are discussing a client's mental health condition in a public place where their conversation can be overheard by others. This is a violation of the client's right to privacy and confidentiality.
The co-workers could be held liable for breaching the client's confidentiality and may face disciplinary action or legal consequences. It is important for healthcare providers to maintain confidentiality to protect their clients' privacy and trust.

Correct Answer is D
Explanation
This statement may give the client false reassurance because it dismisses the client's concerns without acknowledging or addressing them. It is important for the nurse to listen to the client's concerns and provide appropriate interventions and support rather than simply dismissing their worries with a blanket statement. The other
Options (a, b, and c) are observations of the client's behavior or appearance, and do not provide false reassurance.
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