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 A
Explanation
Choice A reason: HIPAA requires client consent to disclose protected health information, like psychological evaluations, to third parties such as employers. This response upholds confidentiality laws, ensuring the client’s privacy is protected while clearly communicating the legal process for information release, making it the most appropriate and compliant action.
Choice B reason: Forwarding the call to the doctor delays the response and does not directly address the confidentiality requirement. While the doctor may handle consent, the nurse can directly inform the employer about the need for signed consent, maintaining clarity and legal compliance in protecting patient privacy.
Choice C reason: Refusing to confirm or deny the client’s presence is overly restrictive and not necessary for an employer’s request. It avoids addressing the consent process, which is the legal requirement for releasing information, making it less direct and potentially confusing in this context.
Choice D reason: Stating that information cannot be given is accurate but incomplete, as it does not explain the consent process. Providing a clear path (obtaining signed consent) ensures compliance with confidentiality laws while addressing the employer’s request, making this response less precise than option a).
Correct Answer is C
Explanation
Choice A reason: Defense mechanisms, like denial or projection, can strain relationships by avoiding honest communication or projecting blame, disrupting trust and emotional connection. While they may temporarily reduce anxiety, they hinder interpersonal dynamics, making this a negative outcome rather than a positive one in therapeutic interactions.
Choice B reason: Defense mechanisms can impair problem-solving by avoiding reality (e.g., denial) or displacing emotions, preventing rational analysis of issues. This leads to maladaptive coping, which does not address underlying problems, making it a negative consequence rather than a positive outcome of using defense mechanisms in mental health contexts.
Choice C reason: Defense mechanisms, such as repression or rationalization, temporarily reduce anxiety by shielding the individual from overwhelming emotions or stressors. By mitigating psychological distress, they provide short-term emotional relief, allowing the person to function under stress, making this a positive outcome when used adaptively in mental health management.
Choice D reason: Defense mechanisms can inhibit emotional growth by preventing individuals from confronting and processing emotions, leading to unresolved issues. Overreliance on mechanisms like avoidance stalls emotional development, hindering self-awareness and coping skills, making this a negative outcome rather than a positive benefit of defense mechanisms.
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