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A nurse is assisting with the involuntary admission of a client who has an anxiety disorder and is unable to meet their basic physical needs. Which of the following statements should the nurse make to the client?
- A. You have the right to refuse medications prescribed during your stay.
- B. Your admission status allows you to leave the facility at any time.
- C. Your health care team will review your admission status in 90 days.
- D. You will automatically have a legal guardian appointed during this admission.
Correct Answer: A
Rationale: Clients who are involuntarily admitted to a psychiatric facility retain certain rights, including the right to refuse medications. This is an important part of patient autonomy and informed consent. Even though the client is involuntarily admitted, they must still be provided with information about their treatment options and have the right to make decisions about their medications unless there is a court order stating otherwise.
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A nurse is discussing the care of a client who has alcohol use disorder with another nurse. Which of the following statements should the nurse identify as an indication of countertransference?
- A. The client is just like my parent, who never could quit drinking.
- B. The client needs to accept responsibility for their drinking.
- C. The client asked me to go on a date.
- D. The client shares their feelings openly during group therapy.
Correct Answer: A
Rationale: This statement is an indication of countertransference because the nurse is projecting personal feelings and experiences onto the client. By comparing the client to their parent who struggled with drinking, the nurse may unconsciously treat the client differently based on unresolved emotions or past experiences. Countertransference can interfere with the nurse's ability to provide objective and compassionate care.
A nurse is reinforcing teaching about home care with the family of a client who has Alzheimer's disease and wanders at night. Which of the following instructions should the nurse include?
- A. Keep the client's bedroom area dark at night.
- B. Have the client exercise 30 minutes before bedtime.
- C. Place the client's mattress on the bedroom floor.
- D. Encourage the client to nap often during the day.
Correct Answer: C
Rationale: Placing the client's mattress on the bedroom floor is a practical safety measure for clients with Alzheimer's disease who wander at night. This approach minimizes the risk of injury from falls, as the client will be closer to the ground. By reducing the height of the bed, families can create a safer sleeping environment and help prevent potential injuries due to wandering and confusion.
A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?
- A. You will be given an opioid analgesic before the procedure.
- B. Expect to be confused several hours after the procedure.
- C. You cannot eat or drink for 24 hours before the procedure.
- D. A consent form is not required to have this procedure.
Correct Answer: B
Rationale: Confusion and temporary memory loss are common side effects immediately following ECT. Clients should be informed to expect these cognitive effects, which can last for a few hours to days. Educating the client about these side effects helps prepare them for what to expect post-procedure and ensures they have appropriate support during their recovery period.
A nurse in a pediatric clinic is caring for a school-age child who has a perforated eardrum. The nurse suspects abuse. Which of the following actions should the nurse take?
- A. Inform the parents that the findings must be reported to authorities.
- B. Complete an incident report for risk management.
- C. Interview the child about the suspected abuse with a parent present.
- D. Avoid asking the child what caused the injury.
Correct Answer: A
Rationale: If a nurse suspects child abuse, they are legally required to report it to the appropriate authorities. Informing the parents that the findings must be reported is necessary to comply with mandatory reporting laws. This step ensures that the child receives the necessary protection and that the situation is investigated further by child protective services or law enforcement.
A nurse is monitoring a client who is receiving haloperidol. Which of the following findings is the priority to report to the provider?
- A. Hypoactive bowel sounds in all four quadrants.
- B. Client report of dry mouth.
- C. Constant opening and closing of mouth.
- D. Client report of photosensitivity.
Correct Answer: C
Rationale: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.