A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?
Blood pressure
Cyanosis
Nausea
Petechiae
The Correct Answer is C
Objective data:
Blood pressure (can be measured by the nurse)
Cyanosis (can be observed by the nurse)
Petechiae (can be observed by the nurse)
So, the subjective data in this list is "Nausea." This is information that the client shares with the nurse about their symptoms or feelings.
The objective data includes A-"Blood pressure," B-"Cyanosis," and D-"Petechiae," which are findings that the nurse can measure or observe during the physical examination.
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Correct Answer is D
Explanation
Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.
Options A, B, and C are not examples of false imprisonment:
A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.
B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.
C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.
Correct Answer is C
Explanation
When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.
Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.
The other options are not appropriate for the following reasons:
A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.
B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.
D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.
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