A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Stop the newly licensed nurse from administering the medication.

Demonstrate how to verbally de-escalate the situation.

Discuss the purpose of the medication with the client.

Assess the need for physical restraints.

Answer and Explanation

The Correct Answer is B

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C. discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D. assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

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Correct Answer is D

Explanation

The client's guardian is the legal representative who can provide informed consent for the client who is incompetent. The nurse should ensure that the guardian understands the risks, benefits, and alternatives of the proposed treatment or procedure.

A. A client who has stomach pain before presenting a project to his coworkers. B. A client whose partner died 5 years ago still talks about him in the present tense. C. A client who states she will worry about her grades after she finishes planning a party. D. A client who states she did not get a promotion because her boss dislikes her.

Correct Answer is D

Explanation

Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.

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A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

Correct Answer is D

Explanation

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