A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral anti-anxiety medication. Which of the following actions should the nurse take?

Administer the medication to the client via IM injection.

Offer the client the medication at the next scheduled dose time.

Inform the client that they do not have the right to refuse the medication.

Implement consequences until the client takes the medication.

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering the medication via IM injection against the client's will can be considered a violation of the client's rights, especially in the context of mental health care where consent and autonomy are highly valued. Involuntary treatment, including medication administration, should only be considered in situations where the client poses an immediate risk to themselves or others, which is not indicated in the scenario provided.

Choice B reason: Offering the medication at the next scheduled dose time respects the client's current decision to refuse the medication while also maintaining the prescribed treatment plan. It allows time for the client to reconsider their decision and provides an opportunity for the nurse to engage in further discussion about the benefits and importance of the medication, potentially addressing any concerns or fears the client may have.

Choice C reason: Informing the client that they do not have the right to refuse medication is incorrect and unethical. Patients have the right to informed consent, which includes the right to refuse treatment. This is particularly important in mental health care, where respecting the client's autonomy and rights is essential for building trust and promoting recovery.

Choice D reason: Implementing consequences for refusing medication is coercive and can damage the therapeutic relationship between the nurse and the client. It may also lead to increased resistance and distrust from the client, which can negatively impact their overall care and treatment outcomes.

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Correct Answer is B

Explanation

Choice A reason: While sharing personal experiences can sometimes help in connecting with the grieving individual, it may also shift the focus away from the partner's feelings to the nurse's own experiences. It's important to keep the conversation centered on the partner's emotions and support needs.

Choice B reason: This response acknowledges the partner's feelings without judgment and opens the door for further conversation. It shows empathy and understanding, which are crucial in providing emotional support to someone who is grieving.

Choice C reason: Suggesting a grief counselor is a practical step, but it might be perceived as dismissive if offered too quickly. It's essential to first establish a supportive dialogue and understand the partner's readiness to seek additional help.

Choice D reason: Telling someone they shouldn't feel guilty can invalidate their feelings. Guilt is a common emotion in the grieving process, and it's important to acknowledge it and provide a safe space for the individual to express their feelings.

A. The client is constantly talking. B. The client displays memory loss. C. The client is sleeping over 10 hours a day. D. The client expresses feelings of inferiority.

Correct Answer is A

Explanation

Choice A reason: Constant talking is a common indicator of mania in individuals with bipolar disorder. During manic episodes, clients may experience pressured speech, which is fast, incessant, and difficult to interrupt. This symptom reflects the increased energy and reduced need for sleep that are characteristic of mania.

Choice B reason: While memory loss is not a definitive indicator of mania, it can occur in bipolar disorder. However, it is more commonly associated with either depressive episodes or the aftermath of a manic episode, rather than the manic phase itself.

Choice C reason: Excessive sleep is typically not associated with mania. In fact, a decreased need for sleep is one of the diagnostic criteria for a manic episode. Clients in a manic phase often feel rested after only a few hours of sleep.

Choice D reason: Expressing feelings of inferiority is not typically indicative of mania. Such feelings are more commonly associated with depressive episodes. Manic episodes often involve inflated self-esteem or grandiosity.

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A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral anti-anxiety medication. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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