A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Inform the client that they have the legal right to refuse treatment at any time.

Encourage the client to have the procedure.

Request another nurse to review the procedure with the client.

Obtain consent from the client's family member.

Answer and Explanation

The Correct Answer is A

The nurse should respect the client's autonomy and inform them of their right to refuse treatment, even if it is against medical advice. The nurse should also explore the reasons for the refusal and provide information and support as needed. The other options are not appropriate as they do not respect the client's decision or may violate their privacy.

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Correct Answer is A

Explanation

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

A. Keep a bright light on in the client's room at night. B. Discourage the client from expressing feelings of anger. C. Encourage physical activity for the client during the day. D. Identify and schedule alternative group activities for the client.

Correct Answer is C

Explanation

Physical activity can help improve mood, energy, sleep, and cognitive function in clients who have major depressive disorder. It can also reduce stress and increase self esteem.

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A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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