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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Watching television before bedtime can be stimulating and interfere with the ability to fall asleep. The blue light emitted by screens can also disrupt the body's natural sleep-wake cycle.
Choice B reason: Regular exercise, particularly when done earlier in the day, can help reduce anxiety and improve sleep quality. However, it's important to avoid vigorous exercise close to bedtime as it can be too stimulating.
Choice C reason: Consuming the evening meal too close to bedtime can cause indigestion and interfere with sleep. It's better to finish eating at least 2-3 hours before going to bed.
Choice D reason: Taking long naps, especially later in the day, can make it more difficult to fall asleep at night. If naps are necessary, they should be short and not too close to bedtime.
Correct Answer is []
Explanation
Potential Condition:
a) Schizophrenia
Choice A reason: Schizophrenia is a chronic mental health condition characterized by symptoms such as delusions, hallucinations, disorganized speech, and significant social or occupational dysfunction. The client’s symptoms, including mumbling as if talking to unseen others and the belief that someone is trying to poison them, are indicative of psychotic features commonly associated with schizophrenia. The prescribed medications, clozapine and risperidone, are antipsychotics often used in the treatment of schizophrenia, further supporting this diagnosis.
Actions to Take:
d) Place the client in a room near the nurses’ station This action allows for close observation and quick intervention if the client’s condition worsens or if they exhibit behaviors that could be harmful to themselves or others.
f) Maintain the client taking their prescribed medications Continuing the prescribed antipsychotic medications is crucial for managing the symptoms of schizophrenia and preventing exacerbation of the condition.
Parameters to Monitor:
j) Command hallucinations Monitoring for command hallucinations is important as they can lead to dangerous behaviors, including harm to self or others, if the client acts on these hallucinations.
l) Suicidal ideation Patients with schizophrenia are at an increased risk for suicide, especially during acute episodes or when experiencing command hallucinations. Regular assessment for suicidal ideation is a critical component of care.
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