A nurse is preparing to administer a dose of lamotrigine to a 35-year-old male client in an outpatient mental health clinic.

Exhibits

Click to highlight the information from the drug reference that supports the decision to withhold the lamotrigine.

Drug Reference for Highlighting:
Lamotrigine Classification: Anticonvulsant. Indications: Bipolar disorder maintenance, epilepsy. Contraindications/Precautions: Impaired renal function, impaired hepatic function. Adverse Reactions/Side Effects: Common: Headache, dizziness, diplopia. Rare: Stevens-Johnson syndrome, Drug reaction with eosinophilia and systemic symptoms (DRESS). Interactions: Carbamazepine, phenobarbital, oral contraceptives, valproic acid. Route/Dosage: 25 mg PO daily. Data Collection: Monitor for mood changes and suicidal ideation. Monitor for seizure activity, blood dyscrasias. Monitor for alterations in hepatic and renal function, temperature, rash. Implementation: Can be administered with or without meals. Taper dosage gradually when beginning and discontinuing. Do not abruptly discontinue.

Choice A rationale

"If the provider prescribes medication, I will have to administer it" is an inaccurate statement regarding a voluntarily admitted client's rights. Voluntarily admitted clients generally retain the right to refuse medication, even if it is prescribed by a provider. This response undermines the client's autonomy.

Choice B rationale

"You agreed to take medication when you decided to be admitted" is also generally inaccurate for voluntary admissions. While the client may agree to a treatment plan that includes medication, voluntary admission itself does not automatically equate to mandatory medication administration. The client still has the right to refuse.

Choice C rationale

"You have the right to refuse to take the medication" is the correct and most appropriate response. Voluntarily admitted clients retain their right to informed consent and the right to refuse treatment, including medication, unless there is a specific court order indicating otherwise or an imminent risk of harm to themselves or others. This response respects the client's autonomy.

Choice D rationale

"I can make a list of the medications that you don't want to take" is a helpful action in acknowledging the client's concern and preferences. However, it does not directly address the client's question about their right to refuse medication. While documenting preferences is important, the initial response should clearly state their right to refusal. .

Choice A rationale

A client repeatedly requesting anxiety medication should be assessed, but their behavior does not indicate an immediate safety risk to themselves or others. While their anxiety needs attention, other clients may have more urgent needs. The nurse should acknowledge their request and address it in a timely manner, but not necessarily as the absolute first priority.

Choice B rationale

A client yelling obscenities and throwing clothes is exhibiting escalating and potentially aggressive behavior. This situation poses an immediate risk to the client's safety and the safety of others on the unit. The nurse must intervene promptly to de-escalate the situation, ensure the client's well-being, and prevent potential harm to themselves or others. This behavior indicates a loss of control and requires immediate attention.

Choice C rationale

A client with bipolar disorder who is continuously pacing is displaying psychomotor agitation, which is characteristic of a manic episode. While this behavior warrants assessment and intervention, it does not present the same level of immediate risk as the client who is actively yelling and throwing objects. The pacing client should be monitored and offered interventions to help manage their agitation, but they are not the highest priority in this scenario.

Choice D rationale

A client screaming at other clients in the dayroom is exhibiting aggressive verbal behavior that is disruptive and potentially threatening to others. This situation requires the nurse's intervention to de-escalate the situation, ensure the safety and comfort of the other clients, and address the yelling client's behavior. However, the client actively throwing objects in their room poses a more immediate and direct safety risk.