The healthcare provider prescribes haloperidol 10 mg for a client with severe psychosis, but the client refuses the medication. Which initial nursing action is appropriate?
Restrain the client and give the medication intramuscularly
Inform the client that refusing the medication means not getting any better
Accept the client’s decision and continue to maintain safety
Obtain a discharge order for nonadherence to the medication regimen
The Correct Answer is C
Choice A reason: Restraining and forcibly administering medication violates patient autonomy and ethical principles, potentially escalating agitation in psychosis. It risks physical harm and legal issues, as forced medication requires specific legal orders (e.g., involuntary commitment). Non-invasive approaches like negotiation or assessing refusal reasons are safer and more ethical.
Choice B reason: Stating that refusal prevents improvement is coercive and undermines autonomy. It fails to explore reasons for refusal, such as side effect concerns or psychosis-related mistrust, which are common in severe psychosis. This approach may damage trust and hinder therapeutic alliance, making it inappropriate as an initial action.
Choice C reason: Accepting the client’s refusal respects autonomy while prioritizing safety, critical in psychosis where agitation is common. This allows exploration of refusal reasons (e.g., paranoia) and alternative interventions, maintaining a therapeutic environment. Monitoring ensures no immediate harm, making this the most ethical and safe initial response.
Choice D reason: Obtaining a discharge order for nonadherence is premature and inappropriate, as refusal does not warrant immediate discharge. Psychosis requires ongoing assessment and management, and discharge could exacerbate symptoms or risk harm, making this action contrary to the goal of stabilizing the client’s mental health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hypocalcemia may occur in AKI due to impaired vitamin D activation, but it is not a primary concern in the diuresis phase, where kidneys produce large urine volumes. Calcium imbalances are less immediate than fluid losses, which can rapidly destabilize hemodynamics during this phase.
Choice B reason: In the diuresis phase of AKI, kidneys regain function, producing excessive urine, which can lead to hypovolemia. Fluid loss depletes intravascular volume, causing hypotension, tachycardia, and organ hypoperfusion. Monitoring is critical to prevent dehydration and ensure adequate fluid replacement to maintain hemodynamic stability during recovery.
Choice C reason: Increased blood pressure is more common in the oliguric phase of AKI due to fluid overload. In the diuresis phase, excessive urine output reduces volume, potentially lowering blood pressure. Hypertension is not a typical complication during this phase, making it an incorrect focus for monitoring.
Choice D reason: Hyperkalemia is a concern in the oliguric phase of AKI due to reduced potassium excretion. In the diuresis phase, increased urine output facilitates potassium clearance, reducing hyperkalemia risk. Hypovolemia from excessive fluid loss is a more immediate concern during this phase of AKI recovery.
Correct Answer is D
Explanation
Choice A reason: Improved nutritional status could cause weight gain but is unlikely in AKI with minimal urine output. AKI patients often have anorexia or dietary restrictions, and weight gain from nutrition would not align with oliguria, which suggests fluid retention rather than increased tissue mass from improved nutrition.
Choice B reason: A 3-pound weight gain in 48 hours with minimal urine output is clinically significant in AKI, indicating fluid retention. Normal weight fluctuations are minimal, and this rapid gain, coupled with oliguria, suggests impaired kidney function, potentially leading to fluid overload complications like hypertension or pulmonary edema.
Choice C reason: Early AKI recovery involves increased urine output (diuresis phase), not minimal output. Weight gain with oliguria indicates ongoing kidney dysfunction, not recovery. Recovery would show improved glomerular filtration and urine production, reducing fluid retention, making this finding inconsistent with AKI recovery.
Choice D reason: In AKI, minimal urine output (oliguria) reflects impaired kidney filtration, leading to fluid retention. A 3-pound weight gain in 48 hours corresponds to approximately 1.5 liters of fluid, indicating fluid overload. This can cause hypertension, pulmonary edema, or heart failure, making fluid retention the most likely explanation.
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