A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

Tell the client he cannot refuse the treatment because he was involuntarily committed.

Inform the client that ECT does not require client consent.

Document the client's refusal of the treatment in the medical record.

Ask the client's family to encourage the client to receive ECT.

Answer and Explanation

The Correct Answer is C

The nurse should respect and document the client's right to refuse treatment, even if he was involuntarily committed, unless there is a court order for ECT. The nurse should not coerce, misinform, or pressure the client to receive ECT against his will. 22.

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Correct Answer is B

Explanation

Delirium is an acute confusional state that can have various causes, such as infection, medication, or metabolic imbalance. It is characterized by a sudden onset of altered mental status, fluctuating levels of consciousness, disorientation, and perceptual disturbances.

A. Implement continuous one-to-one observation. B. Encourage the client to participate in group therapy. C. Ask the client to sign a no-suicide contract. D. Establish a rapport to foster trust.

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.

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A nurse is caring for a client who was involuntarily committed and is scheduled to receive electroconvulsive therapy (ECT). The client refuses the treatment and will not discuss why with the health care team. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

Correct Answer is B

Explanation

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

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