The nurse is evaluating clients in the emergency department (ED) for pending mental health admissions. Which client will be admitted for involuntary hospitalization?

A client who states they intend to harm self and others

A client who has diabetes who refuses to follow the prescribed diet

A client who is unable to control rage and is assaulting others

A client who does not bathe regularly or change clothes often

Answer and Explanation

The Correct Answer is A

Choice A reason: Stating intent to harm self and others meets criteria for involuntary hospitalization (e.g., 302 commitment), as it indicates imminent danger. Mental health laws prioritize safety, requiring inpatient evaluation to prevent suicide or violence, making this client eligible for involuntary admission to stabilize their condition.

Choice B reason: Refusing a diabetic diet is nonadherence but does not meet criteria for involuntary mental health hospitalization, which requires mental health-related danger to self or others. This behavior may warrant medical intervention, but it lacks the psychiatric urgency needed for involuntary admission.

Choice C reason: Uncontrolled rage with assaultive behavior indicates imminent danger to others, meeting criteria for involuntary hospitalization. Mental health laws allow commitment to protect others and stabilize the client, as assault reflects a severe mental health crisis requiring inpatient intervention to prevent further harm.

Choice D reason: Poor hygiene does not constitute imminent danger to self or others, a requirement for involuntary hospitalization. While it may indicate mental health issues, it lacks the acute risk needed for commitment, making outpatient evaluation or support more appropriate than involuntary admission.

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Correct Answer is C

Explanation

Choice A reason: Allowing a client with suicidal comments to leave against medical advice is unsafe, as it risks self-harm without immediate intervention. Providing resources does not address acute suicide risk, which requires inpatient stabilization to ensure safety, making this action inappropriate in the context of expressed suicidal ideation.

Choice B reason: Contacting family to persuade the client to stay does not address immediate suicide risk. While family support may be helpful, it lacks legal authority to prevent discharge and does not ensure safety, making it less effective than initiating a commitment for a client with suicidal intent.

Choice C reason: A 302 involuntary commitment is appropriate for a client expressing suicidal ideation, indicating imminent danger to self. This legal action ensures safety through inpatient evaluation and treatment, preventing self-harm. Mental health laws prioritize protection in such cases, making this the most appropriate nursing action.

Choice D reason: Calling security to detain the client is coercive and lacks legal basis without a formal commitment process. It may escalate agitation and violate autonomy. A 302 commitment is the proper legal mechanism to ensure safety for a suicidal client, making detention by security inappropriate.

A. Restrain the client and give the medication intramuscularly B. Inform the client that refusing the medication means not getting any better C. Accept the client’s decision and continue to maintain safety D. Obtain a discharge order for nonadherence to the medication regimen

Correct Answer is C

Explanation

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.

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The nurse is evaluating clients in the emergency department (ED) for pending mental health admissions. Which client will be admitted for involuntary hospitalization?

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Correct Answer is C

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