The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate?

Accept the client's decision and continue to maintain safety.

Obtain a discharge order for nonadherence to the medication regimen.

Restrain the client and give the medication intramuscularly.

Inform the client that refusing the medication means not getting any better.

Answer and Explanation

The Correct Answer is A

Every individual has the right to refuse medical treatment, including medications, as long as they are competent to make that decision. It is essential to respect the client's autonomy and right to make decisions about their own health care. When a client refuses medication, the nurse should document the refusal, inform the healthcare provider, and explore the reasons behind the refusal if possible.

The other options are not appropriate for the following reasons:

B- Obtaining a discharge order for nonadherence: While it is essential to address nonadherence to medication, discharging the client solely for refusing the medication may not be the best course of action. Instead, the nurse should work collaboratively with the healthcare team to address the client's concerns and explore alternative treatment options.

C- Restraining the client and giving the medication intramuscularly: Restraints should only be used as a last resort when a client presents an imminent danger to themselves or others, and it must be done in accordance with facility policies and legal regulations. Using restraints to administer medication against a client's will is a violation of their rights and is not an appropriate response to medication refusal.

D-Informing the client that refusing the medication means not getting any better: This response may be seen as coercive and manipulative. It is not ethical to use fear or guilt to persuade a client to take medication against their will. Instead, the nurse should provide information about the potential benefits and risks of the medication and address the client's concerns or fears about the treatment. Ultimately, the decision to take the medication should be left to the client after they have been fully informed about their options.

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Correct Answer is D

Explanation

A-Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data

B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.

C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.

D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs

A. Anger B. Acceptance C. Bargaining D. Depression

Correct Answer is C

Explanation

The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of bargaining in the grieving process. During this stage, individuals may try to negotiate or make deals with a higher power or with fate in an attempt to postpone or change the outcome of their situation. In this case, the client is expressing a desire to live long enough to witness the birth of their first grandchild, which represents an attempt to negotiate with their illness and impending death.

It's important for the nurse to be supportive and empathetic during this stage of grieving and to provide emotional support to the client as they navigate their feelings and thoughts about their illness and impending death. Explanation: The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of grieving known as bargaining.

In the context of the five stages of grief proposed by Elisabeth Kübler-Ross, bargaining is the third stage. During this stage, individuals may attempt to negotiate or make deals with a higher power or the universe to change the outcome of their situation. They may express thoughts like "If only I could see this happen before I die," as a way to find some sense of control or hope amidst their terminal illness.

In this scenario, the client's desire to see their first grandchild born reflects the bargaining stage, where they are trying to find meaning and hope in their terminal condition by wishing for a specific event to occur before their passing.

The other stages of grief include:

A. Anger - In this stage, individuals may feel resentful, frustrated, or outraged about their situation or the circumstances leading to their illness.

B. Acceptance - The final stage in Kübler-Ross's model, acceptance, involves coming to terms with one's imminent death and finding peace and resolution.

D. Depression - In this stage, individuals may experience profound sadness and a sense of loss related to their impending death and the life they will leave behind.

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The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Correct Answer is D

Explanation

The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?

Correct Answer is C

Explanation

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