A nurse on a mental health unit is caring for a client who has bipolar disorder. Which of the following actions by the nurse incorporates the ethical principle of fidelity?

Documents the client's refusal of their prescribed medications.

Provides a quiet space for the client if they become agitated

Informs the client about the adverse effects of their medication

Returns at the promised time to sit and talk with the client

Answer and Explanation

The Correct Answer is D

A. Documents the client's refusal of their prescribed medications: Accurate documentation reflects professional responsibility and legal accountability, but it is related to veracity and accountability rather than fidelity, which focuses on keeping commitments.

B. Provides a quiet space for the client if they become agitated: Creating a safe environment demonstrates beneficence and respect for the client’s well-being, but it does not specifically reflect fidelity, which emphasizes faithfulness and honoring promises.

C. Informs the client about the adverse effects of their medication: Educating the client supports informed consent and autonomy, aligning with the principle of veracity, but it does not directly involve keeping a commitment or promise.

D. Returns at the promised time to sit and talk with the client: Returning at the promised time demonstrates fidelity by maintaining trust and keeping commitments made to the client. This action strengthens the therapeutic relationship and models reliability and consistency in care.

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Correct Answer is B

Explanation

A. Bring a security guard whenever approaching the client: Involving security unnecessarily can escalate tension and reinforce hostile behavior. Safety is important, but this intervention should be reserved for situations where the client poses an immediate physical threat.

B. Use a calm, clear tone when speaking to the client: Maintaining a calm, clear, and neutral tone helps de-escalate hostility and reduces the likelihood of verbal or physical aggression. Clear communication also sets boundaries while promoting a therapeutic environment for clients with schizophrenia.

C. Encourage the client to participate in a board game: While engaging in structured activities can be beneficial for socialization and distraction, this intervention does not directly address the immediate hostile outbursts or prevent escalation. It is more of a supportive measure than a priority intervention.

D. Touch the client on the shoulder to console them: Physical touch can be misinterpreted by clients with schizophrenia, potentially triggering anxiety, agitation, or further hostility. Nonverbal boundaries should be maintained unless the client explicitly consents to touch in a therapeutic context.

A. Medical history B. Heart rate C. Respiratory rate D. Pupils E. Oxygen saturation F. Orientation

Correct Answer is ["B","D","F"]

Explanation

A. Medical history: While limited medical history may affect care planning, the lack of other medical conditions does not pose an immediate safety concern and does not require urgent reporting.

B. Heart rate: A heart rate of 121/min indicates tachycardia, which, in the context of recent substance injection and agitation, may signal acute toxicity or cardiovascular stress. This finding requires immediate attention and reporting to the charge nurse.

C. Respiratory rate: A respiratory rate of 20/min is within normal limits for an adult and does not indicate immediate compromise. While monitoring is necessary, it does not require urgent reporting.

D. Pupils: Dilated pupils can indicate recent stimulant use or other substance effects, suggesting acute intoxication. This finding may correlate with life-threatening complications and should be reported immediately for safety and intervention planning.

E. Oxygen saturation: Oxygen saturation of 98% on room air is within normal limits and does not indicate hypoxia, so it is not an urgent concern in this context.

F. Orientation: The client is oriented only to person, indicating confusion or impaired cognitive function, possibly due to intoxication or withdrawal. This acute change in mental status is a safety concern and should be reported immediately.

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A nurse on a mental health unit is caring for a client who has bipolar disorder. Which of the following actions by the nurse incorporates the ethical principle of fidelity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

A nurse is assisting in the admission of a client to an inpatient mental health facility. The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the charge nurse immediately? Select all that apply.

Correct Answer is ["B","D","F"]

Explanation

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