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

The statement, "I will find a support group to help me through this," indicates that the client's coping skills are adequate. Seeking support from others who have experienced a similar loss can be an effective way to cope with feelings of loneliness and vulnerability after the death of a spouse. Support groups provide a safe and understanding environment where individuals can share their experiences, feelings, and struggles, and receive emotional support from others who can relate to their situation.

Option A suggests an overconfidence in coping skills and may not fully acknowledge the need for external support during a challenging time.

Option B indicates a sense of feeling abandoned, which could be a sign of struggling coping skills.

Option C suggests confusion and difficulty accepting the loss, which may indicate inadequate coping skills at the moment.

A. The nurse must discuss the findings with the parents and give them the opportunity to explain. B. Talk to the child and find out if they are experiencing sexual abuse or inappropriate touching. C. The nurse should talk with another co-worker to be sure the nurse is correct about the assessment. D. Accurately and thoroughly document the findings and report to the appropriate authorities.

Correct Answer is D

Explanation

When a school nurse suspects that a child is being sexually abused, the priority action is to ensure the child's safety and well-being. Option D, accurately and thoroughly documenting the findings and reporting to the appropriate authorities, is the most critical step in protecting the child.

Child abuse, including sexual abuse, is a serious concern that requires immediate attention and intervention. In many jurisdictions, healthcare professionals, including school nurses, are mandated reporters, which means they are legally obligated to report suspected cases of child abuse to child protective services or other appropriate authorities.

Options A, B, and C are not appropriate as the child's safety is the top priority:

A. Discussing the findings with the parents and giving them the opportunity to explain could potentially place the child at further risk if the parents are involved in the abuse or are unwilling to address the situation.

B. Talking to the child and finding out if they are experiencing sexual abuse or inappropriate touching should not be the first step without involving child protective services or other appropriate authorities. The child may be frightened or reluctant to disclose abuse directly to the nurse, especially if the abuser is a family member or someone known to the child.

C. Talking with another co-worker to confirm the assessment may delay the necessary action and reporting to protect the child.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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