A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?
Schedule the medication at meal times.
Request the family talk to the provider about administering the medication by injection.
Inform the family that the client has the right not to take the medication.
Ask the family what foods the client likes.
The Correct Answer is C
The nurse should inform the family that the client has the right to refuse medication. It is important to
respect the client's autonomy and right to make decisions about their own care.
a) Scheduling the medication at meal times does not address the issue of the client refusing their medication.
b) Requesting that the family talk to the provider about administering the medication by injection may be an option, but it does not address the issue of informed consent.
d) Asking the family what foods the client likes does not address the issue of informed consent and could be seen as a way to deceive the client into taking their medication.
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Correct Answer is C
Explanation
c. Hallucination
In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).
In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.
Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.
Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.
Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.
Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.
Correct Answer is B
Explanation
b. "I should join a support group to help me be successful."
The statement that indicates an understanding of smoking cessation teaching is option b: "I should join a support group to help me be successful." Joining a support group is a beneficial strategy for quitting smoking as it provides social support, encouragement, and shared experiences with others who are also trying to quit.
Option a is incorrect because using nicotine patches does not allow for continued smoking as it delivers nicotine without the harmful effects of smoking.
Option c is incorrect because nicotine replacement therapy (NRT) is a safe and effective method to manage nicotine withdrawal and does not cause cancer.
Option d is incorrect because varenicline is a medication that helps reduce nicotine cravings and withdrawal symptoms, and it does not make a person addicted to nicotine.
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