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A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states, 'I am not going to take that medicine, and you can't make me.' What action should the nurse take?
- A. Administer the medication via a nasogastric tube.
- B. Substitute an injectable form of the medication.
- C. Encourage the client to take the medicine because it will help her sleep.
- D. Document in the client's record that the medication was refused.
Correct Answer: D
Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.
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The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?
- A. Excessive work activity.
- B. Decreased need for sleep.
- C. Medication management.
- D. Inflated self-esteem.
Correct Answer: C
Rationale: The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of mania, such as excessive work activity (A), decreased need for sleep (B), and inflated self-esteem (D); however, these problems do not have the priority of medication management. Managing the medications is crucial to stabilize the client's condition and prevent potential harm associated with untreated bipolar disorder.
A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assign the client to a teen support group.
- B. Assess intake and output.
- C. Monitor for wheezing and apnea.
- D. Limit visitors to family members only.
Correct Answer: B
Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.
What information should the nurse include in the client's teaching about starting a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder?
- A. It may take several weeks for the medication to take effect.
- B. You can stop taking the medication once you feel better.
- C. Avoid foods high in tyramine while on this medication.
- D. You should expect an immediate improvement in mood.
Correct Answer: A
Rationale: The correct answer is A: "It may take several weeks for the medication to take effect." SSRIs typically take several weeks to reach their full effect, and it's important to set realistic expectations for the client. Choice B is incorrect because stopping the medication abruptly can lead to withdrawal symptoms and worsening of depression. Choice C is unrelated to SSRI therapy and pertains more to MAOIs. Choice D is incorrect as SSRIs do not provide immediate improvement in mood; rather, they require time to exert their therapeutic effects.
When caring for a client who has overdosed on PCP, the nurse should be especially cautious about which of the following client behaviors?
- A. Visual hallucinations
- B. Violent behavior
- C. Bizarre behavior
- D. Loud screaming
Correct Answer: B
Rationale: The correct answer is B: 'Violent behavior.' When a client has overdosed on PCP, the nurse should be particularly cautious about the manifestation of violent behavior. PCP overdose can lead to aggressive and unpredictable actions, posing a significant risk to both the client and healthcare providers. Visual hallucinations (choice A), bizarre behavior (choice C), and loud screaming (choice D) can also occur with PCP overdose, but the primary concern should be the potential for violent behavior, making it the most critical behavior to monitor and manage.
On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, 'I don't want to discuss this; it's private and personal.' Which response by the LVN/LPN is the most therapeutic?
- A. I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care.
- B. This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment.
- C. I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential.
- D. I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality.
Correct Answer: D
Rationale: The correct response is D. Respecting the client's privacy while acknowledging the difficulty of the situation and explaining the professional obligation to maintain confidentiality is the most therapeutic approach. This response shows empathy, understanding, and a commitment to confidentiality, which can help build trust and encourage the client to open up. Choices A, B, and C do not effectively address the client's concerns or emphasize the importance of confidentiality in a sensitive manner, making them less therapeutic responses in this situation.